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Ueno R, Reddy MP, Jones D, Pilcher D, Subramaniam A. The impact of frailty on survival times up to one year among patients admitted to ICU with in-hospital cardiac arrest. J Crit Care 2024; 83:154842. [PMID: 38865757 DOI: 10.1016/j.jcrc.2024.154842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 04/18/2024] [Accepted: 06/06/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND In-hospital cardiac arrest (IHCA) is a serious medical emergency. When IHCA occurs in patients with frailty, short-term survival is poor. However, the impact of frailty on long-term survival is unknown. METHODS We performed a retrospective multicentre study of all critically ill adult (age ≥ 16 years) patients admitted to Australian intensive care units (ICU) between 1st January 2018 to 31st March 2022. We included all patients who had an IHCA within the 24 h before ICU admission with a documented Clinical Frail Scale (CFS). The primary outcome was median survival up to one year following ICU admission. The effect of frailty on one-year survival was assessed using a Cox proportional hazards model, adjusting for age, sex, comorbidities, sequential organ failure assessment (SOFA) score, and hospital type. RESULTS We examined 3769 patients, of whom 30.8% (n = 1160) were frail (CFS ≥ 5). The median survival was significantly shorter for patients with frailty (median [IQR] days 19 [1-365] vs 302 [9-365]; p < 0.001). The overall one-year mortality was worse for the patients with frailty when compared to the non-frail group (64.8% [95%CI 61.9-67.5] vs 36.4% [95%CI 34.5-38.3], p < 0.001). Each unit increment in the CFS was associated with 22% worse survival outcome (adjusted Hazard ratio = 1.22, 95%-CI 1.19-1.26), after adjustment for confounders. The survival trend was similar among patients who survived the hospitalization. CONCLUSION In this retrospective multicentre study, frailty was associated with poorer one-year survival in patients admitted to Australian ICUs following an IHCA.
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Affiliation(s)
- Ryo Ueno
- Intensive Care Medicine, Eastern Health, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Victoria, Australia.
| | - Mallikarjuna Ponnapa Reddy
- Intensive Care Medicine, Peninsula Health, Victoria, Australia; Intensive Care Medicine, Calvary Hospital Health, Canberra, Australia
| | - Daryl Jones
- Australian and New Zealand Intensive Care Research Centre, Monash University, Victoria, Australia; Intensive Care Medicine, Austin Health, Victoria, Australia; University of Melbourne, Victoria, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Monash University, Victoria, Australia; Intensive Care Medicine, Alfred Health, Victoria, Australia; Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resources Evaluation, Victoria, Australia
| | - Ashwin Subramaniam
- Australian and New Zealand Intensive Care Research Centre, Monash University, Victoria, Australia; Intensive Care Medicine, Peninsula Health, Victoria, Australia; Intensive Care Medicine, Monash Health, Victoria, Australia; Monash University, Peninsula Clinical School, Victoria, Australia
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Doppalapudi S, Khan B, Adrish M. Reimagining critical care: Trends and shifts in 21 st century medicine. World J Crit Care Med 2024; 13:94020. [DOI: 10.5492/wjccm.v13.i3.94020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 05/02/2024] [Accepted: 06/25/2024] [Indexed: 08/30/2024] Open
Abstract
Critical care medicine has undergone significant evaluation in the 21st century, primarily driven by advancements in technology, changes in healthcare delivery, and a deeper understanding of disease processes. Advancements in technology have revolutionized patient monitoring, diagnosis, and treatment in the critical care setting. From minimally invasive procedures to advances imaging techniques, clinicians now have access to a wide array of tools to assess and manage critically ill patients more effectively. In this editorial we comment on the review article published by Padte S et al wherein they concisely describe the latest developments in critical care medicine.
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Affiliation(s)
- Sai Doppalapudi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, BronxCare Health System/Icahn School of Medicine at Mount Sinai, Bronx, NY 10467, United States
| | - Bilal Khan
- Pulmonary, William P. Clements High School, Sugar Land, TX 77479, United States
| | - Muhammad Adrish
- Section of Pulmonary and Critical Care Medicine, Ben Taub Hospital/Baylor College of Medicine, Houston, TX 77030, United States
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Ruck JM, Bush EL. Use of Extracorporeal Membrane Oxygenation for Patients with Coronavirus Disease 2019 Infection. Adv Surg 2024; 58:249-273. [PMID: 39089781 PMCID: PMC11294677 DOI: 10.1016/j.yasu.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic was a cataclysmic event that infected over 772 million and killed over 6.9 million people worldwide. The pandemic pushed hospitals and society to their limits and resulted in incredibly severe respiratory disease in millions of people. This severe respiratory disease often necessitated maximum medical therapy, including the use of extracorporeal membrane oxygenation. While our understanding of COVID-19 and its treatment continue to evolve, we review the current evidence to guide the care of patients with severe COVID-19 infection.
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Affiliation(s)
- Jessica M Ruck
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Errol L Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Yoshida T, Shimizu S, Fushimi K, Mihara T. Changing clinical practice and prognosis for severe respiratory failure over time: A nationwide inpatient database study. Respir Investig 2024; 62:778-784. [PMID: 38986214 DOI: 10.1016/j.resinv.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 06/26/2024] [Accepted: 07/05/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Severe respiratory failure requires numerous interventions and its clinical implementation changes over time. We aimed to clarify the clinical practice and prognosis of severe respiratory failure and its changes over time. METHODS In a nationwide Japanese administrative database from 2016 to 2019, we identified nonoperative patients with severe respiratory failure without congestive heart failure as the main diagnosis who received mechanical ventilation (MV) for more than four days. We examined trends in patient characteristics, adjunctive interventions, and prognosis. RESULTS Among 66,905 patients included in this study, patients received antibiotics (90%), high-dose corticosteroids (14%), low-dose corticosteroids (18%), and 51% were admitted to the critical care unit. Hospital mortality was 35%. Median mechanical ventilation lasted 10 days. Tracheostomy occurred in 23% of cases. Median critical care and hospital stays were 10 and 25 days, respectively. Among survivors, 23% had mechanical ventilation dependency at hospital discharge. Large relative changes in adjunctive therapies included fentanyl (30%-38%), rocuronium (4.4%-6.7%), vasopressin (3.8%-6.0%), early rehabilitation (27%-38%), extracorporeal membrane oxygenation (0.7%-1.2%), dopamine (15%-10%), and sivelestat (8.6%-3.5%). No notable changes were seen in mechanical ventilation duration, tracheostomy, critical care unit stay, hospital stay, or ventilator dependency at discharge, except for a slight reduction in hospital mortality (36%-34%). CONCLUSIONS Several adjunctive therapies for severe respiratory failure changed from 2016 to 2019, with an increase in evidence-based practices and a slight decrease in hospital mortality.
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Affiliation(s)
- Takuo Yoshida
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2, Seto, Kanazawa, Yokohama, 236-0027, Japan; Department of Emergency Medicine, The Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo 105-8471, Japan.
| | - Sayuri Shimizu
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2, Seto, Kanazawa, Yokohama, 236-0027, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Takahiro Mihara
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2, Seto, Kanazawa, Yokohama, 236-0027, Japan; Department of Anesthesiology, Yokohama City University School of Medicine, 3-9, Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
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Farrimond R, Yusuff H, Charlton M. Use of Early Veno-Venous Extracorporeal Membrane Oxygenation Following Lightning Strike-Induced Acute Lung Injury. J Cardiothorac Vasc Anesth 2024; 38:2028-2034. [PMID: 38890080 DOI: 10.1053/j.jvca.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 04/06/2024] [Accepted: 04/10/2024] [Indexed: 06/20/2024]
Affiliation(s)
- Rohan Farrimond
- ST7 Anaesthesia and Intensive Care Medicine, Sheffield Teaching Hospitals NHS Foundation Trust
| | - Hakeem Yusuff
- Honorary Senior Lecturer / Consultant in ECMO, ICM and Anaesthetics, Glenfield Hospital, University Hospitals of Leicester NHS Foundation Trust, Leicester, United Kingdom
| | - Matthew Charlton
- ST7 Anaesthesia and Intensive Care Medicine, Sheffield Teaching Hospitals NHS Foundation Trust; Honorary Senior Lecturer / Consultant in ECMO, ICM and Anaesthetics, Glenfield Hospital, University Hospitals of Leicester NHS Foundation Trust, Leicester, United Kingdom.
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Peng K, Hu L, Huang X, He Y, Wu X, Li H, Zhang W, Zhu H, Wang Z, Chen C. Innovative Percutaneous 3-Stitch Suture Technique for Site Closure in Venoarterial Extracorporeal Membrane Oxygenation Decannulation Without Direct Artery Repair: A Case Series. ASAIO J 2024; 70:787-794. [PMID: 38587868 PMCID: PMC11356694 DOI: 10.1097/mat.0000000000002198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024] Open
Abstract
No previous studies have reported the use of a percutaneous suture technique performed by bedside intensivists for site closure during decannulation without direct artery repair in venoarterial extracorporeal membrane oxygenation (VA-ECMO) cases. Thus, the objective of this study was to evaluate the safety and effectiveness of this alternative approach. This retrospective study included 26 consecutive patients who underwent percutaneous VA-ECMO decannulation at Maoming People's Hospital. Bedside percutaneous suture technique performed by intensivists facilitated cannula site closure. Primary outcome was successful closure without additional interventions. Secondary outcomes included procedural time, surgical conversion rate, complications (bleeding, vascular/wound complications, neuropathy, lymphocele), procedure-related death. Follow-up ultrasound were conducted within 6 months after discharge. All patients achieved successful site hemostasis with a median procedural time of 28 minutes. Procedure-related complications included minor bleeding (7.7%), acute lower limb ischemia (15.4%), venous thrombus (11.5%), minor arterial stenosis (7.7%), wound infection (4.2%), delayed healing (15.4%), and wound secondary suturing (6.3%). No procedure-related deaths occurred. Follow-up vascular ultrasound revealed two cases (7.7%) of minor arterial stenosis. The perivascular suture technique may offer intensivists a safe and effective alternative method for access site closure without direct artery suture during ECMO decannulation.
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Affiliation(s)
- Kaiyi Peng
- From the Department of Critical Care Medicine, Maoming People’s Hospital, Maoming, China
| | - Linhui Hu
- From the Department of Critical Care Medicine, Maoming People’s Hospital, Maoming, China
- The Center of Scientific Research, Maoming People’s Hospital, Maoming, China
| | - Xiangwei Huang
- From the Department of Critical Care Medicine, Maoming People’s Hospital, Maoming, China
| | - Yuemei He
- The Center of Scientific Research, Maoming People’s Hospital, Maoming, China
| | - Xinxin Wu
- From the Department of Critical Care Medicine, Maoming People’s Hospital, Maoming, China
| | - Huihua Li
- From the Department of Critical Care Medicine, Maoming People’s Hospital, Maoming, China
| | - Wentao Zhang
- From the Department of Critical Care Medicine, Maoming People’s Hospital, Maoming, China
| | - Hengling Zhu
- From the Department of Critical Care Medicine, Maoming People’s Hospital, Maoming, China
| | - Zheng Wang
- From the Department of Critical Care Medicine, Maoming People’s Hospital, Maoming, China
| | - Chunbo Chen
- Department of Critical Care Medicine, Shenzhen People’s Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
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Paredes RM, Inman B, Davis WT, Castaneda M, Mireles AA, Baldwin DS, Rodriguez DC, Medellin KL, Ng PC, Maddry JK. Efficacy of a Single Day Extracorporeal Membrane Oxygenation Training Course for Critical Care Air Transport Team Eligible Personnel. Mil Med 2024; 189:e2211-e2219. [PMID: 38687647 DOI: 10.1093/milmed/usae138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/22/2024] [Accepted: 03/18/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is an advanced medical technology that is used to treat respiratory and heart failure. The U.S. military has used ECMO in the care of combat casualties during Operation Enduring Freedom and Operation Iraqi Freedom as well as in the treatment of patients during the recent Coronavirus Disease 2019 pandemic. However, few Military Health System personnel have training and experience in the use of ECMO therapy. To address this dearth of expertise, we developed and evaluated an accelerated ECMO course for military medical personnel. OBJECTIVES To compare the efficacy of an accelerated ECMO course for Military Health System critical care teams. METHODS Seventeen teams, each consisting of a physician and nurse, underwent a 5-h accelerated ECMO course. Similar to our previous live-tissue ECMO training program (phases I and II), each team watched prerecorded ECMO training lectures. Subjects then practiced priming the ECMO circuit, cannulating ECMO, initiating ECMO, and correcting common complications on an ECMO simulation model. An added component to this phase III project included transportation and telemedicine consultation availability. Training success was evaluated via knowledge and confidence assessments, and observation of each team attempting to initiate ECMO on a Yorkshire swine patient model, transport the patient model, and troubleshoot complications with the support of telemedicine consultation when desired. RESULTS Seventeen teams successfully completed the course. All seventeen teams (100%) successfully placed the swine on veno-arterial ECMO. Of those, 15 teams successfully transitioned to veno-arterial-venous ECMO. The knowledge assessments of physicians and nurses increased by 12.2% from pretest (mean of 62.1%, SD 10.4%) to posttest (mean of 74.4%, SD 8.2%), P < .0001; their confidence assessments increased by 41.1% from pretest (mean of 20.1%, SD 11.8%) to posttest (mean of 61.2%, SD 18.6%). CONCLUSIONS An abbreviated 1-day lecture and hands-on task-trainer-based ECMO course resulted in a high rate of successful skill demonstration and improvement of physicians' and nurses' knowledge assessments and confidence levels, similar to our previous live-tissue training program. When compared to our previous studies, the addition of telemedicine and patient transportation to this study did not affect the duration or performance of procedures.
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Affiliation(s)
- R Madelaine Paredes
- United States Air Force, 59th Medical Wing, Clinical Resuscitation, Emergency Science, Triage and Toxicology (CRESTT), Lackland AFB, TX 78236, USA
| | - Brannon Inman
- Department of Critical Care Medicine, Orlando Regional Medical Center, Orlando, FL 32806, USA
| | - William T Davis
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
- United States Air Force, 59th Medical Wing, En Route Care Research Center, Lackland AFB, TX 78236, USA
| | - Maria Castaneda
- United States Air Force, 59th Medical Wing, En Route Care Research Center, Lackland AFB, TX 78236, USA
| | - Allyson A Mireles
- United States Air Force, 59th Medical Wing, En Route Care Research Center, Lackland AFB, TX 78236, USA
| | - Darren S Baldwin
- United States Air Force, 59th Medical Wing, En Route Care Research Center, Lackland AFB, TX 78236, USA
| | - Dylan C Rodriguez
- United States Air Force, 59th Medical Wing, Clinical Resuscitation, Emergency Science, Triage and Toxicology (CRESTT), Lackland AFB, TX 78236, USA
| | - Kimberly L Medellin
- United States Air Force, 59th Medical Wing, En Route Care Research Center, Lackland AFB, TX 78236, USA
| | - Patrick C Ng
- Emergency Medicine/Medical Toxicology, Department of Emergency Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX 78229, USA
| | - Joseph K Maddry
- United States Air Force, 59th Medical Wing, Clinical Resuscitation, Emergency Science, Triage and Toxicology (CRESTT), Lackland AFB, TX 78236, USA
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
- Clinician Scientist Investigator Opportunity Network (CSION), United States Air Force, 59th Medical Wing Lackland ABF, TX 78236, USA
- F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA
- Department of Clinical Investigation, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
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Murphy S, Flatley M, Piper L, Mason P, Sams V. Indications and Outcomes for Adult Extracorporeal Membrane Oxygenation at a Military Referral Facility. Mil Med 2024; 189:2004-2008. [PMID: 38743578 DOI: 10.1093/milmed/usae189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/22/2024] [Accepted: 04/01/2024] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION Extracorporeal life support, including extracorporeal membrane oxygenation (ECMO), is a potentially life-saving adjunct to therapy in patients experiencing pulmonary and/or cardiac failure. The U.S. DoD has only one ECMO center, in San Antonio, Texas. In this study, we aimed to analyze outcomes at this center in order to determine whether they are on par with those reported elsewhere in the literature. MATERIALS AND METHODS In this observational study, we analyzed data from patients treated with ECMO at the only DoD ECMO center between September 2012 and April 2020. The primary outcome was survival to discharge, and secondary outcomes were discharge disposition and incidence of complications. RESULTS One hundred and forty-three patients were studied, with a 70.6% rate of survival to discharge. Of the patients who survived, 32.7% were discharged home; 32.7% were discharged to a rehabilitation facility; and 33.7% were transferred to another hospital, 29.4% of whom were transferred to lung transplant centers. One patient left against medical advice. Incidence of ECMO-related complications were as follows: 64 patients (44.7%) experienced hemorrhagic complications, 80 (55.9%) had renal complications, 61 (42.6%) experienced cardiac complications, 39 (27.3%) had pulmonary complications, and 5 patients (3.5%) experienced limb ischemia. We found that these outcomes were comparable to those reported in the literature. CONCLUSIONS Extracorporeal membrane oxygenation can be an efficacious adjunct in management of critically ill patients who require pulmonary and/or cardiac support. This single-center observational study demonstrated that the DoD's only ECMO center has outcomes comparable with the reported data in Extracorporeal Life Support Organization's registry.
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Affiliation(s)
- Samantha Murphy
- Department of Surgery, UT Health San Antonio, San Antonio, TX 78229, USA
| | - Meaghan Flatley
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Lydia Piper
- Department of Surgery, Landstuhl Regional Medical Center, Landstuhl 66849, Germany
| | - Phillip Mason
- Department of Anesthesiology, UT Health San Antonio, San Antonio, TX 78229, USA
| | - Valerie Sams
- Department of Surgery, Division of Trauma and Surgical Critical Care, The University of Cincinnati Medical Center, Cincinnati, OH 45219, USA
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Cave C, Samano D, Sharma AM, Dickinson J, Salomon J, Mahapatra S. Acute respiratory distress syndrome: A review of ARDS across the life course. J Investig Med 2024:10815589241270612. [PMID: 39092841 DOI: 10.1177/10815589241270612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Acute respiratory distress syndrome (ARDS) is a multifactorial, inflammatory lung disease with significant morbidity and mortality that predominantly requires supportive care in its management. Although initially described in adult patients, the diagnostic definitions for ARDS have evolved over time to accurately describe this disease process in pediatric and, more recently, neonatal patients. The management of ARDS in each age demographic has converged in the application of lung-protective ventilatory strategies to mitigate the primary disease process and prevent its exacerbation by limiting ventilator-induced lung injury. However, differences arise in the preferred ventilatory strategies or adjunctive pulmonary therapies used to mitigate each type of ARDS. In this review, we compare and contrast the epidemiology, common etiologies, pathophysiology, diagnostic criteria, and outcomes of ARDS across the lifespan. Additionally, we discuss in detail the different management strategies used for each subtype of ARDS and spotlight how these strategies were applied to mitigate poor outcomes during the COVID-19 pandemic. This review is geared toward both clinicians and clinician-scientists as it not only summarizes the latest information on disease pathogenesis and patient management in ARDS across the lifespan but also highlights knowledge gaps for further investigative efforts. We conclude by projecting how future studies can fill these gaps in research and what improvements may be envisioned in the management of NARDS and PARDS based on the current breadth of literature on adult ARDS treatment strategies.
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Affiliation(s)
- Caleb Cave
- Division of Neonatology, and Division of Pulmonology, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, University of Nebraska Medical Center, Omaha, NE, USA
| | - Dannielle Samano
- Division of Pulmonary, Sleep, and Critical Care Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Abhineet M Sharma
- Division of Neonatology, and Division of Pulmonology, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, University of Nebraska Medical Center, Omaha, NE, USA
| | - John Dickinson
- Division of Pulmonary, Sleep, and Critical Care Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jeffrey Salomon
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sidharth Mahapatra
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, University of Nebraska Medical Center, Omaha, NE, USA
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Boscolo A, Bruni A, Giani M, Garofalo E, Sella N, Pettenuzzo T, Bombino M, Palcani M, Rezoagli E, Pozzi M, Falcioni E, Pistollato E, Biamonte E, Murgolo F, D'Arrigo G, Gori M, Tripepi GL, Gottin L, Longhini F, Grasso S, Navalesi P, Foti G. Retrospective ANalysis of multi-drug resistant Gram-nEgative bacteRia on veno-venous extracorporeal membrane oxygenation. The multicenter RANGER STUDY. Crit Care 2024; 28:279. [PMID: 39192287 DOI: 10.1186/s13054-024-05068-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Accepted: 08/15/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND Veno-venous extracorporeal membrane oxygenation (V-V ECMO) is a rapidly expanding life-support technique worldwide. The most common indications are severe hypoxemia and/or hypercapnia, unresponsive to conventional treatments, primarily in cases of acute respiratory distress syndrome. Concerning potential contraindications, there is no mention of microbiological history, especially related to multi-drug resistant (MDR) bacteria isolated before V-V ECMO placement. Our study aims to investigate: (i) the prevalence and incidence of MDR Gram-negative (GN) bacteria in a cohort of V-V ECMOs; (ii) the risk of 1-year mortality, especially in the case of predetected MDR GN bacteria; and (iii) the impact of annual hospital V-V ECMO volume on the probability of acquiring MDR GN bacteria. METHODS All consecutive adults admitted to the Intensive Care Units of 5 Italian university-affiliated hospitals and requiring V-V ECMO were screened. Exclusion criteria were age < 18 years, pregnancy, veno-arterial or mixed ECMO-configuration, incomplete records, survival < 24 h after V-V ECMO. A standard protocol of microbiological surveillance was applied and MDR profiles were identified using in vitro susceptibility tests. Cox-proportional hazards models were applied for investigating mortality. RESULTS Two hundred and seventy-nine V-V ECMO patients (72% male) were enrolled. The overall MDR GN bacteria percentage was 50%: 21% (n.59) detected before and 29% (n.80) after V-V ECMO placement. The overall 1-year mortality was 42%, with a higher risk observed in predetected patients (aHR 2.14 [1.33-3.47], p value 0.002), while not in 'V-V ECMO-acquired MDR GN bacteria' group (aHR 1.51 [0.94-2.42], p value 0.090), as compared to 'non-MDR GN bacteria' group (reference). Same findings were found considering only infections. A larger annual hospital V-V ECMO volume was associated with a lower probability of acquiring MDR GN bacteria during V-V ECMO course (aOR 0.91 [0.86-0.97], p value 0.002). CONCLUSIONS 21% of MDR GN bacteria were detected before; while 29% after V-V ECMO connection. A history of MDR GN bacteria, isolated before V-V ECMO, was an independent risk factor for mortality. The annual hospital V-V ECMO volume affected the probability of acquiring MDR GN bacteria. Trial Registration ClinicalTrial.gov Registration Number NCTNCT06199141, date 12.26.2023.
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Affiliation(s)
- Annalisa Boscolo
- Department of Medicine (DIMED), University of Padua, 13 Gallucci Street, 35121, Padua, Italy
- Institute of Anesthesia and Critical Care, Padua University Hospital, Padua, Italy
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Andrea Bruni
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Marco Giani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Critical Care, IRCSS San Gerardo Dei Tintori, Monza, Italy
| | - Eugenio Garofalo
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Nicolò Sella
- Institute of Anesthesia and Critical Care, Padua University Hospital, Padua, Italy
| | - Tommaso Pettenuzzo
- Institute of Anesthesia and Critical Care, Padua University Hospital, Padua, Italy
| | - Michela Bombino
- Department of Emergency and Critical Care, IRCSS San Gerardo Dei Tintori, Monza, Italy
| | - Matteo Palcani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Critical Care, IRCSS San Gerardo Dei Tintori, Monza, Italy
| | - Matteo Pozzi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Critical Care, IRCSS San Gerardo Dei Tintori, Monza, Italy
| | - Elena Falcioni
- Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
- Cardiothoracic and Vascular Intensive Care Unit, Verona University Hospital, Verona, Italy
| | - Elisa Pistollato
- Department of Medicine (DIMED), University of Padua, 13 Gallucci Street, 35121, Padua, Italy
| | - Eugenio Biamonte
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Francesco Murgolo
- Department of Precision and Regenerative Medicine and Ionian Area, School of Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Graziella D'Arrigo
- CNR-IFC, Institute of Clinical Physiology of Reggio Calabria, Reggio Calabria, Italy
| | - Mercedes Gori
- CNR-IFC, Institute of Clinical Physiology of Rome, Rome, Italy
| | | | - Leonardo Gottin
- Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
- Cardiothoracic and Vascular Intensive Care Unit, Verona University Hospital, Verona, Italy
| | - Federico Longhini
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Salvatore Grasso
- Department of Precision and Regenerative Medicine and Ionian Area, School of Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Paolo Navalesi
- Department of Medicine (DIMED), University of Padua, 13 Gallucci Street, 35121, Padua, Italy.
- Institute of Anesthesia and Critical Care, Padua University Hospital, Padua, Italy.
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Critical Care, IRCSS San Gerardo Dei Tintori, Monza, Italy
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11
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Boesing C, Rocco PRM, Luecke T, Krebs J. Positive end-expiratory pressure management in patients with severe ARDS: implications of prone positioning and extracorporeal membrane oxygenation. Crit Care 2024; 28:277. [PMID: 39187853 PMCID: PMC11348554 DOI: 10.1186/s13054-024-05059-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 08/06/2024] [Indexed: 08/28/2024] Open
Abstract
The optimal strategy for positive end-expiratory pressure (PEEP) titration in the management of severe acute respiratory distress syndrome (ARDS) patients remains unclear. Current guidelines emphasize the importance of a careful risk-benefit assessment for PEEP titration in terms of cardiopulmonary function in these patients. Over the last few decades, the primary goal of PEEP usage has shifted from merely improving oxygenation to emphasizing lung protection, with a growing focus on the individual pattern of lung injury, lung and chest wall mechanics, and the hemodynamic consequences of PEEP. In moderate-to-severe ARDS patients, prone positioning (PP) is recommended as part of a lung protective ventilation strategy to reduce mortality. However, the physiologic changes in respiratory mechanics and hemodynamics during PP may require careful re-assessment of the ventilation strategy, including PEEP. For the most severe ARDS patients with refractory gas exchange impairment, where lung protective ventilation is not possible, veno-venous extracorporeal membrane oxygenation (V-V ECMO) facilitates gas exchange and allows for a "lung rest" strategy using "ultraprotective" ventilation. Consequently, the importance of lung recruitment to improve oxygenation and homogenize ventilation with adequate PEEP may differ in severe ARDS patients treated with V-V ECMO compared to those managed conservatively. This review discusses PEEP management in severe ARDS patients and the implications of management with PP or V-V ECMO with respect to respiratory mechanics and hemodynamic function.
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Affiliation(s)
- Christoph Boesing
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha do Fundão, Rio de Janeiro, Brazil
| | - Thomas Luecke
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Joerg Krebs
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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12
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Wang R, Tang X, Li X, Li Y, Liu Y, Li T, Zhao Y, Wang L, Li H, Li M, Li H, Tong Z, Sun B. Early reapplication of prone position during venovenous ECMO for acute respiratory distress syndrome: a prospective observational study and propensity-matched analysis. Ann Intensive Care 2024; 14:127. [PMID: 39162882 PMCID: PMC11336129 DOI: 10.1186/s13613-024-01365-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 08/11/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND A combination of prone positioning (PP) and venovenous extracorporeal membrane oxygenation (VV-ECMO) is safe, feasible, and associated with potentially improved survival for severe acute respiratory distress syndrome (ARDS). However, whether ARDS patients, especially non-COVID-19 patients, placed in PP before VV-ECMO should continue PP after a VV-ECMO connection is unknown. This study aimed to test the hypothesis that early use of PP during VV-ECMO could increase the proportion of patients successfully weaned from ECMO support in severe ARDS patients who received PP before ECMO. METHODS In this prospective observational study, patients with severe ARDS who were treated with VV-ECMO were divided into two groups: the prone group and the supine group, based on whether early PP was combined with VV-ECMO. The proportion of patients successfully weaned from VV-ECMO and 60-day mortality were analyzed before and after propensity score matching. RESULTS A total of 165 patients were enrolled, 50 in the prone and 115 in the supine group. Thirty-two (64%) and 61 (53%) patients were successfully weaned from ECMO in the prone and the supine groups, respectively. The proportion of patients successfully weaned from VV-ECMO in the prone group tended to be higher, albeit not statistically significant. During PP, there was a significant increase in partial pressure of arterial oxygen (PaO2) without a change in ventilator or ECMO settings. Tidal impedance shifted significantly to the dorsal region, and lung ultrasound scores significantly decreased in the anterior and posterior regions. Forty-five propensity score-matched patients were included in each group. In this matched sample, the prone group had a higher proportion of patients successfully weaned from VV-ECMO (64.4% vs. 42.2%; P = 0.035) and lower 60-day mortality (37.8% vs. 60.0%; P = 0.035). CONCLUSIONS Patients with severe ARDS placed in PP before VV-ECMO should continue PP after VV-ECMO support. This approach could increase the probability of successful weaning from VV-ECMO. TRIAL REGISTRATION ClinicalTrials.Gov: NCT04139733. Registered 23 October 2019.
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Affiliation(s)
- Rui Wang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Xiao Tang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Xuyan Li
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Ying Li
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Yalan Liu
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Ting Li
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Yu Zhao
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Li Wang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Haichao Li
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Meng Li
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Hu Li
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Bing Sun
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China.
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13
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Burrell A, Bailey MJ, Bellomo R, Buscher H, Eastwood G, Forrest P, Fraser JF, Fulcher B, Gattas D, Higgins AM, Hodgson CL, Litton E, Martin EL, Nair P, Ng SJ, Orford N, Ottosen K, Paul E, Pellegrino V, Reid L, Shekar K, Totaro RJ, Trapani T, Udy A, Ziegenfuss M, Pilcher D. Conservative or liberal oxygen targets in patients on venoarterial extracorporeal membrane oxygenation. Intensive Care Med 2024:10.1007/s00134-024-07564-8. [PMID: 39162827 DOI: 10.1007/s00134-024-07564-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 07/17/2024] [Indexed: 08/21/2024]
Abstract
PURPOSE Patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) frequently develop arterial hyperoxaemia, which may be harmful. However, lower oxygen saturation targets may also lead to harmful episodes of hypoxaemia. METHODS In this registry-embedded, multicentre trial, we randomly assigned adult patients receiving VA-ECMO in an intensive care unit (ICU) to either a conservative (target SaO2 92-96%) or to a liberal oxygen strategy (target SaO2 97-100%) through controlled oxygen administration via the ventilator and ECMO gas blender. The primary outcome was the number of ICU-free days to day 28. Secondary outcomes included ICU-free days to day 60, mortality, ECMO and ventilation duration, ICU and hospital lengths of stay, and functional outcomes at 6 months. RESULTS From September 2019 through June 2023, 934 patients who received VA-ECMO were reported to the EXCEL registry, of whom 300 (192 cardiogenic shock, 108 refractory cardiac arrest) were recruited. We randomised 149 to a conservative and 151 to a liberal oxygen strategy. The median number of ICU-free days to day 28 was similar in both groups (conservative: 0 days [interquartile range (IQR) 0-13.7] versus liberal: 0 days [IQR 0-13.7], median treatment effect: 0 days [95% confidence interval (CI) - 3.1 to 3.1]). Mortality at day 28 (59/159 [39.6%] vs 59/151 [39.1%]) and at day 60 (64/149 [43%] vs 62/151 [41.1%] were similar in conservative and liberal groups, as were all other secondary outcomes and adverse events. The conservative group experienced 44 (29.5%) major protocol deviations compared to 2 (1.3%) in the liberal oxygen group (P < 0.001). CONCLUSIONS In adults receiving VA-ECMO in ICU, a conservative compared to a liberal oxygen strategy, did not affect the number of ICU-free days to day 28.
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Affiliation(s)
- Aidan Burrell
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Michael J Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Department of Critical Care, School of Medicine, University of Melbourne, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, VIC, Australia
| | - Hergen Buscher
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Glenn Eastwood
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Paul Forrest
- Intensive Care Service, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - John F Fraser
- Institute of Molecular Bioscience, The University of Queensland, Herston, QLD, Australia
- Critical Care Research Group, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Bentley Fulcher
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - David Gattas
- Intensive Care Service, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- The George Institute for Global Health, Newtown, NSW, Australia
| | - Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
- Department of Critical Care, School of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Murdoch, WA, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcomes and Resources Evaluation, Melbourne, VIC, Australia
| | - Emma-Leah Martin
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Priya Nair
- The George Institute for Global Health, Newtown, NSW, Australia
- Intensive Care Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Sze J Ng
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Neil Orford
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, VIC, Australia
- School of Medicine, Deakin University, Waurn Ponds, Geelong, VIC, Australia
| | - Kelly Ottosen
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Eldho Paul
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Vincent Pellegrino
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Liadain Reid
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Kiran Shekar
- Institute of Molecular Bioscience, The University of Queensland, Herston, QLD, Australia
- Adult Intensive Care Unit, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Richard J Totaro
- Intensive Care Service, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Andrew Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Marc Ziegenfuss
- Critical Care Research Group, The Prince Charles Hospital, Chermside, QLD, Australia
- Adult Intensive Care Unit, The Prince Charles Hospital, Chermside, QLD, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia.
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcomes and Resources Evaluation, Melbourne, VIC, Australia.
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14
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Nutma S, Roesink O, van Heugten CM, Hofmeijer J. Long term functioning with poor neurologic outcome after cardiac arrest. Resuscitation 2024:110375. [PMID: 39174000 DOI: 10.1016/j.resuscitation.2024.110375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 08/15/2024] [Accepted: 08/17/2024] [Indexed: 08/24/2024]
Abstract
AIM Around six percent of comatose patients after cardiac arrest have a Cerebral Performance Categories score of three (CPC3) at six months after the arrest, classified as severe neurological disability. There is limited knowledge regarding the likelihood of further recovery in the cognitive, emotional, and quality of life domains. We aimed to estimate the probability of recovery towards independency. METHODS From a prospective Registry on comatose cardiac arrest patients admitted between 2013 and 2017 in two Dutch hospitals, we included patients with a CPC3 at six months after cardiac arrest. We followed patients up to November 2023. The primary outcome measure was the CPC score at time of follow up. Secondary outcomes were scores on questionnaires on cognition, mood, and quality of life according to the minimal dataset of acquired brain injury. RESULTS In our cohort of 667 patients, 29 (4.3%) had a CPC3 score at six months (median age 68 years, 83% male). At a median time of eight years after cardiac arrest, sixteen patients had died. Twelve of thirteen alive patients still had a CPC3 score (92%) and one a CPC2 (8%). Seven patients agreed with further interviewing, one showed independency in activities of daily living (14%). Six patients (86%) reported limitations due to physical and one (14%) due to emotional problems. All had severe cognitive impairment. Six (86%) missed cognitive rehabilitation. CONCLUSION Our study shows that while the probability of recovery towards independence for patients with severe neurological disability at six months after cardiac arrest is limited, most long-term survivors are satisfied with their quality of life.
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Affiliation(s)
- Sjoukje Nutma
- Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede, the Netherlands; Department of Neurology, Medisch Spectrum Twente, Enschede, the Netherlands.
| | - Ozzy Roesink
- Department of Health Sciences, Technical Medical Center, University of Twente, Enschede, the Netherlands; Department of Critical Care, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Caroline M van Heugten
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands; Limburg Brain Injury Center, Maastricht University, Maastricht, the Netherlands
| | - Jeannette Hofmeijer
- Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede, the Netherlands; Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
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15
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Marcus JE, Shah A, Peek GJ, MacLaren G. Nosocomial Infections in Adults Receiving Extracorporeal Membrane Oxygenation: A Review for Infectious Diseases Clinicians. Clin Infect Dis 2024; 79:412-419. [PMID: 38442737 DOI: 10.1093/cid/ciae120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/13/2024] [Accepted: 02/26/2024] [Indexed: 03/07/2024] Open
Abstract
Over the past 10 years, there has been a rapid expansion in the use of extracorporeal membrane oxygenation (ECMO) in the care of patients with refractory cardiac or respiratory failure. Infectious diseases clinicians must reconcile conflicting evidence from limited studies as they develop practices at their own institutions, which has resulted in considerably different practices globally. This review describes infection control and prevention as well as antimicrobial prophylaxis strategies in this population. Data on diagnostics and treatment for patients receiving ECMO with a focus on diagnostic and antimicrobial stewardship is then examined. This review summarizes gaps in the current ECMO literature and proposes future needs, including developing clear definitions for infections and encouraging transparent reporting of practices at individual facilities in future clinical trials.
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Affiliation(s)
- Joseph E Marcus
- Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, Texas, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Aditya Shah
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Giles J Peek
- Congenital Heart Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Graeme MacLaren
- Antimicrobial Stewardship Program, Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore
- Cardiothoracic Intensive Care Unit, National University Hospital, Singapore
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16
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Sandrio S, Beck G, Krebs J, Otto M. [Peripheral extracorporeal membrane oxygenation in perioperative medicine : Principles, indications and challenges]. CHIRURGIE (HEIDELBERG, GERMANY) 2024:10.1007/s00104-024-02135-5. [PMID: 39145870 DOI: 10.1007/s00104-024-02135-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/02/2024] [Indexed: 08/16/2024]
Abstract
In recent years the number of patients treated in intensive care units by extracorporeal membrane oxygenation (ECMO) due to severe respiratory failure or cardiogenic shock has steadily increased [1]. Consequently, the number of invasive procedures and operations in these patients has also increased. A fundamental understanding of these systems and the clinical indications is therefore helpful for the practicing (non-cardiac) surgeon. This review article focuses on peripheral ECMO procedures: venovenous (V-V) ECMO for patients with respiratory failure and venoarterial (V-A) ECMO for circulatory support in cardiogenic shock.
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Affiliation(s)
- Stany Sandrio
- Klinik für Anästhesiologie, Operative Intensiv- und Schmerzmedizin, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - Grietje Beck
- Klinik für Anästhesiologie, Operative Intensiv- und Schmerzmedizin, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Joerg Krebs
- Klinik für Anästhesiologie, Operative Intensiv- und Schmerzmedizin, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Matthias Otto
- Klinik für Anästhesiologie, Operative Intensiv- und Schmerzmedizin, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
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17
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Fumagalli B, Giani M, Bombino M, Fumagalli D, Merelli M, Chiesa G, Rona R, Bellani G, Rezoagli E, Foti G. Pressure Support Ventilation During Extracorporeal Membrane Oxygenation Support in Patients With Acute Respiratory Distress Syndrome. ASAIO J 2024:00002480-990000000-00542. [PMID: 39116298 DOI: 10.1097/mat.0000000000002285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024] Open
Abstract
In the initial phases of veno-venous extracorporeal membrane oxygenation (VV ECMO) support for severe acute respiratory distress syndrome (ARDS), ultraprotective controlled mechanical ventilation (CMV) is typically employed to limit the progression of lung injury. As patients recover, transitioning to assisted mechanical ventilation can be considered to reduce the need for prolonged sedation and paralysis. This study aimed to evaluate the feasibility of transitioning to pressure support ventilation (PSV) during VV ECMO and to explore variations in respiratory mechanics and oxygenation parameters following the transition to PSV. This retrospective monocentric study included 191 adult ARDS patients treated with VV ECMO between 2009 and 2022. Within this population, 131 (69%) patients were successfully switched to PSV during ECMO. Pressure support ventilation was associated with an increase in respiratory system compliance (p = 0.02) and a reduction in pulmonary shunt fraction (p < 0.001). Additionally, improvements in the cardiovascular Sequential Organ Failure Assessment score and a reduction in pulmonary arterial pressures (p < 0.05) were recorded. Ninety-four percent of patients who successfully transitioned to PSV were weaned from ECMO, and 118 (90%) were discharged alive from the intensive care unit (ICU). Of those who did not reach PSV, 74% died on ECMO, whereas the remaining patients were successfully weaned from extracorporeal support. In conclusion, PSV is feasible during VV ECMO and potentially correlates with improvements in respiratory function and hemodynamics.
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Affiliation(s)
- Benedetta Fumagalli
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Marco Giani
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Michela Bombino
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Denise Fumagalli
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Milena Merelli
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Gaia Chiesa
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Roberto Rona
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Giacomo Bellani
- Department of Medical Sciences, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari di Trento, Trento, Italy
| | - Emanuele Rezoagli
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Giuseppe Foti
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
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18
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Sharp D, McKenzie D, Padayachee L, Subramaniam A. Frailty as a trigger for goals-of-care discussions in rapid response calls: A single-centre retrospective cohort study. Aust Crit Care 2024:S1036-7314(24)00200-5. [PMID: 39127605 DOI: 10.1016/j.aucc.2024.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 06/26/2024] [Accepted: 06/28/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Timely goals-of-care (GOC) discussions are essential for end-of-life planning, particularly during acute hospital admissions, where ambiguity often persists. Frailty, prevalent in the ageing population and linked to adverse outcomes, underscores the need to align treatment strategies with quality of life. Recognising frailty as a trigger for GOC discussions during rapid response calls (RRCs) is critical for efficient resource management and improving patient outcomes. METHODS This single-centre retrospective cohort study included all hospitalised patients aged ≥65 years admitted between September 2021 and June 2023 who experienced an RRC. Frailty was assessed using the Clinical Frailty Scale (CFS) during the RRC. The primary outcome was to investigate whether frailty, specifically assessed by the CFS as screened during an RRC, could be a suitable clinical trigger for initiating GOC discussions. We also aimed to identify the proportion of patients with frailty (CFS score: ≥5) and predictors at the time of RRC, resulting in recommendations for GOC discussions. RESULTS Among 4954 patients, 1685 (34.0%) were classified as frail (CFS score: ≥5). Recommendations increased with frailty levels (nonfrail [CFS score: 1-4]: 6.6%, mildly frail [CFS score: 5]: 19.3%, moderate-to-severely frail [CFS score: 6-9]: 32.2%; p < 0.001). Frailty independently increased the probability of GOC recommendations during an RRC (area under the receiver operating characteristic curve = 0.71). The CFS cut-off point for GOC recommendations was ≥5. The presence of frailty was associated with higher odds of receiving GOC recommendations for mildly frail (CFS score: 5; odds ratio [OR] = 2.53; 95% confidence interval: 1.96-3.27) and moderate-to-severely frail (CFS score: 6-9; OR = 4.69; 95% confidence interval: 3.81-5.78) compared to nonfrail patients. CONCLUSION Frailty, identified during an RRC, served as a robust trigger for GOC recommendations, highlighting the importance of tailored proactive discussions before episodes of deterioration. Higher levels of frailty (CFS score: ≥5) demonstrate practical markers for aiding clinicians with proactive GOC discussions.
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Affiliation(s)
- D Sharp
- Department of Intensive Care, Epworth HealthCare, Richmond, Victoria, Australia; Department of Medicine, Nursing and Health Sciences, School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care, Frankston Hospital, Peninsula Health, Frankston, Victoria, Australia; Department of Intensive Care, Victorian Heart Hospital, Monash Health, Clayton, Victoria, Australia.
| | - D McKenzie
- Research Development and Governance Unit, Epworth HealthCare, Richmond, Melbourne, Victoria, Australia; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - L Padayachee
- Department of Intensive Care, Epworth HealthCare, Richmond, Victoria, Australia
| | - A Subramaniam
- Department of Intensive Care, Frankston Hospital, Peninsula Health, Frankston, Victoria, Australia; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care Medicine, Dandenong Hospital, Monash Health, Dandenong, Victoria, Australia; Department of Intensive Care, Epworth HealthCare, Geelong, Victoria, Australia; Department of Medicine, Peninsula Clinical School, Monash University, Frankston, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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19
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Kanaris C. Fifteen-minute consultation: A guide to paediatric post-resuscitation care following return of spontaneous circulation. Arch Dis Child Educ Pract Ed 2024:edpract-2023-325922. [PMID: 39122265 DOI: 10.1136/archdischild-2023-325922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 07/24/2024] [Indexed: 08/12/2024]
Abstract
Paediatric resuscitation is a key skill for anyone in medicine who is involved in the care of children. Basic and advance paediatric life support courses are crucial in teaching those skills nationwide in a way that is memorable, protocolised and standardised. These courses are vital in the dissemination and upkeep of both theoretical and practical knowledge of paediatric resuscitation, with their primary aim being the return of spontaneous circulation. While sustaining life is important, preserving a life with quality, one with good functional and neurological outcomes should be the gold standard of any resuscitative attempt. Good neurological outcomes are dependent, in large part, on how well the postresuscitation stage is managed. This stage does not start in the intensive care unit, it starts at the point at which spontaneous circulation has been reinstated. The aim of this paper is to provide a basic overview of the main strategies that should be followed in order to minimise secondary brain injury after successful resuscitation attempts.
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Affiliation(s)
- Constantinos Kanaris
- Paediatric Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Blizard Institute, Queen Mary University of London, London, UK
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20
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Zochios V, Nasa P, Yusuff H, Schultz MJ, Antonini MV, Duggal A, Dugar S, Ramanathan K, Shekar K, Schmidt M. Definition and management of right ventricular injury in adult patients receiving extracorporeal membrane oxygenation for respiratory support using the Delphi method: a PRORVnet study. Expert position statements. Intensive Care Med 2024:10.1007/s00134-024-07551-z. [PMID: 39102027 DOI: 10.1007/s00134-024-07551-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Accepted: 07/05/2024] [Indexed: 08/06/2024]
Abstract
PURPOSE Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is an integral part of the management algorithm of patients with severe respiratory failure refractory to evidence-based conventional treatments. Right ventricular injury (RVI) pertaining to abnormalities in the dimensions and/or function of the right ventricle (RV) in the context of VV-ECMO significantly influences mortality. However, in the absence of a universally accepted RVI definition and evidence-based guidance for the management of RVI in this very high-risk patient cohort, variations in clinical practice continue to exist. METHODS Following a systematic search of the literature, an international Steering Committee consisting of eight healthcare professionals involved in the management of patients receiving ECMO identified domains and knowledge gaps pertaining to RVI definition and management where the evidence is limited or ambiguous. Using a Delphi process, an international panel of 52 Experts developed Expert position statements in those areas. The process also conferred RV-centric overarching open questions for future research. Consensus was defined as achieved when 70% or more of the Experts agreed or disagreed on a Likert-scale statement or when 80% or more of the Experts agreed on a particular option in multiple-choice questions. RESULTS The Delphi process was conducted through four rounds and consensus was achieved on 31 (89%) of 35 statements from which 24 Expert position statements were derived. Expert position statements provided recommendations for RVI nomenclature in the setting of VV-ECMO, a multi-modal diagnostic approach to RVI, the timing and parameters of diagnostic echocardiography, and VV-ECMO settings during RVI assessment and management. Consensus was not reached on RV-protective driving pressure thresholds or the effect of prone positioning on patient-centric outcomes. CONCLUSION The proposed definition of RVI in the context of VV-ECMO needs to be validated through a systematic aggregation of data across studies. Until further evidence emerges, the Expert position statements can guide informed decision-making in the management of these patients.
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Affiliation(s)
- Vasileios Zochios
- Glenfield Hospital Extracorporeal Membrane Oxygenation Unit, University Hospitals of Leicester National Health Service Trust, Glenfield, Groby Road, Leicester, LE3 9QP, UK.
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.
| | - Prashant Nasa
- Critical Care Medicine, NMC Specialty Hospital, Dubai, United Arab Emirates
- Internal Medicine, College of Medicine and Health Sciences, Al Ain, Abu Dhabi, United Arab Emirates
| | - Hakeem Yusuff
- Glenfield Hospital Extracorporeal Membrane Oxygenation Unit, University Hospitals of Leicester National Health Service Trust, Glenfield, Groby Road, Leicester, LE3 9QP, UK
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Marcus J Schultz
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Anesthesiology, Critical Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Marta Velia Antonini
- Intensive Care Unit, Bufalini Hospital, AUSL Della Romagna, Cesena, Italy
- PhD program in Cardio-Nephro-Thoracic Sciences, University of Bologna, Bologna, Italy
| | - Abhijit Duggal
- Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Kollengode Ramanathan
- National University Hospital, Singapore, 119074, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia
- Queensland University of Technology, Brisbane, QLD, Australia
- University of Queensland, Brisbane and Bond University, Gold Coast, QLD, Australia
| | - Matthieu Schmidt
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, AP-HP, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
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21
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Davies MG, Hart JP. Extracorporal Membrane Oxygenation in Massive Pulmonary Embolism. Ann Vasc Surg 2024; 105:287-306. [PMID: 38588954 DOI: 10.1016/j.avsg.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/09/2024] [Accepted: 02/10/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Massive pulmonary embolism (MPE) carries significant 30-day mortality risk, and a change in societal guidelines has promoted the increasing use of extracorporeal membrane oxygenation (ECMO) in the immediate management of MPE-associated cardiovascular shock. This narrative review examines the current status of ECMO in MPE. METHODS A literature review was performed from 1982 to 2022 searching for the terms "Pulmonary embolism" and "ECMO," and the search was refined by examining those publications that covered MPE. RESULTS In the patient with MPE, veno-arterial ECMO is now recommended as a bridge to interventional therapy. It can reliably decrease right ventricular overload, improve RV function, and allow hemodynamic stability and restoration of tissue oxygenation. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Applying ECMO is also associated with substantial multisystem morbidity due to systemic inflammatory response, bleeding with coagulopathy, hemorrhagic stroke, renal dysfunction, and acute limb ischemia, which must be factored into the outcomes. CONCLUSIONS The application of ECMO in MPE should be combined with an aggressive interventional pulmonary interventional program and should strictly adhere to the current selection criteria.
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Affiliation(s)
- Mark G Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Department of Vascular and Endovascular Surgery, Ascension Health, Waco, TX.
| | - Joseph P Hart
- Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI
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22
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Galazzi A, Petrei M, Palese A. Tools used to assess comfort among patients undergoing high flow nasal cannula: A scoping review. Intensive Crit Care Nurs 2024; 83:103719. [PMID: 38718552 DOI: 10.1016/j.iccn.2024.103719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/11/2024] [Accepted: 04/30/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVE The aims were twofold: (a) to map tools documented in the literature to evaluate comfort among patients undergoing high flow nasal cannula (HFNC) treatment; and (b) to assess if the retrieved tools have been validated for this purpose. METHODS A scoping review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). In July 2023, PubMed, Scopus, CINAHL and Cochrane Library were consulted. Studies assessing comfort in adult, paediatric, and neonatal patients undergoing HFNC were included. RESULTS Seventy-four articles were included, among which nine (12.2 %) investigated comfort as the primary aim. Twenty-five different tools were found, classifiable into 14 types, mostly unidimensional and originating from those measuring pain. The most widely used was the Visual Analogic Scale (n = 27, 35.6 %) followed by the Numerical Rating Scale (n = 11, 14.5 %) and less defined generic tools (n = 10, 13.2 %) with different metrics (e.g. 0-5, 0-10, 0-100). Only the General Comfort Questionnaire and the Comfort Scale were specifically validated for the assessment of comfort among adults and children, respectively. CONCLUSION Although the comfort of patients undergoing HFNC is widely investigated in the literature, there is a scarcity of tools specifically validated in this field. Those used have been validated mainly to assess pain, suggesting the need to inform patients to prevent confusion while measuring comfort during HFNC and to develop more research in the field. IMPLICATIONS FOR CLINICAL PRACTICE Comfort assessment is an important aspect of nursing care. Given the lack of validation studies in the field, efforts in research are recommended.
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Affiliation(s)
| | - Matteo Petrei
- Department of Medicine, University of Udine, Udine, Italy
| | - Alvisa Palese
- Department of Medicine, University of Udine, Udine, Italy
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23
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Hileman BA, Martucci G, Subramanian H. Metabolic support for patients on extra-corporeal membrane oxygenation. Curr Opin Crit Care 2024; 30:305-310. [PMID: 38841988 DOI: 10.1097/mcc.0000000000001162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW The purpose of the review is to summarize recent research on metabolic support during extracorporeal membrane oxygenation. In this review, we cover the evidence on nutritional supplementation, both the route of supplementation, timing of initiation of supplementation as well as quantities of supplementation needed. In addition, we discuss the recent trend in awake extracorporeal membrane oxygenation (ECMO) and its benefits to patients. RECENT FINDINGS As ECMO use continues to increase over the last few years, for both cardiovascular as well as respiratory failure, the need to optimize the metabolic states of patients has arisen. Increasing evidence has pointed towards this hitherto unexplored domain of patient care having a large impact on outcomes. Additionally, strategies such as awake ECMO for select patients has allowed them to preserve muscle mass which could aid in a faster recovery. SUMMARY There is a role of optimal metabolic support in the early recovery of patients on ECMO that is currently under-recognized. Future directions of research that aim to improve post ECMO outcomes must focus on this area.
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Affiliation(s)
| | - Gennaro Martucci
- Department of Anesthesia and Intensive Care, ISMETT, Palermo, Italy
| | - Harikesh Subramanian
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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24
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Schaller SJ, Scheffenbichler FT, Bein T, Blobner M, Grunow JJ, Hamsen U, Hermes C, Kaltwasser A, Lewald H, Nydahl P, Reißhauer A, Renzewitz L, Siemon K, Staudinger T, Ullrich R, Weber-Carstens S, Wrigge H, Zergiebel D, Coldewey SM. Guideline on positioning and early mobilisation in the critically ill by an expert panel. Intensive Care Med 2024; 50:1211-1227. [PMID: 39073582 DOI: 10.1007/s00134-024-07532-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/15/2024] [Indexed: 07/30/2024]
Abstract
A scientific panel was created consisting of 23 interdisciplinary and interprofessional experts in intensive care medicine, physiotherapy, nursing care, surgery, rehabilitative medicine, and pneumology delegated from scientific societies together with a patient representative and a delegate from the Association of the Scientific Medical Societies who advised methodological implementation. The guideline was created according to the German Association of the Scientific Medical Societies (AWMF), based on The Appraisal of Guidelines for Research and Evaluation (AGREE) II. The topics of (early) mobilisation, neuromuscular electrical stimulation, assist devices for mobilisation, and positioning, including prone positioning, were identified as areas to be addressed and assigned to specialist expert groups, taking conflicts of interest into account. The panel formulated PICO questions (addressing the population, intervention, comparison or control group as well as the resulting outcomes), conducted a systematic literature review with abstract screening and full-text analysis and created summary tables. This was followed by grading the evidence according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and a risk of bias assessment. The recommendations were finalized according to GRADE and voted using an online Delphi process followed by a final hybrid consensus conference. The German long version of the guideline was approved by the professional associations. For this English version an update of the systematic review was conducted until April 2024 and recommendation adapted based on new evidence in systematic reviews and randomized controlled trials. In total, 46 recommendations were developed and research gaps addressed.
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Affiliation(s)
- Stefan J Schaller
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.
| | | | | | - Manfred Blobner
- Department of Anaesthesiology and Intensive Care Medicine, Ulm University, Ulm, Germany
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine and Health, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Julius J Grunow
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Uwe Hamsen
- Ruhr University Bochum, Bochum, Germany
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Carsten Hermes
- Hochschule für Angewandte Wissenschaften Hamburg (HAW Hamburg), Hamburg, Germany
- Akkon-Hochschule für Humanwissenschaften, Berlin, Germany
| | - Arnold Kaltwasser
- Academy of the District Hospitals Reutlingen, Kreiskliniken Reutlingen, Reutlingen, Germany
| | - Heidrun Lewald
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine and Health, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Nydahl
- University Hospital of Schleswig-Holstein, Kiel, Germany
- Institute of Nursing Science and Development, Paracelsus Medical University, Salzburg, Austria
| | - Anett Reißhauer
- Department of Rehabilitation Medicine, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Leonie Renzewitz
- Department of Physiotherapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Karsten Siemon
- Department of Pneumology, Fachkrankenhaus Kloster Grafschaft, Schmallenberg, Germany
| | - Thomas Staudinger
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Roman Ullrich
- Department of Anaesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Center Vienna, Vienna, Austria
| | - Steffen Weber-Carstens
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Hermann Wrigge
- Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital, Halle, Germany
- Medical Faculty, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | | | - Sina M Coldewey
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.
- Septomics Research Center, Jena University Hospital, Jena, Germany.
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25
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Penfold RS, Hunt A. Redefining risk in peri-operative frailty: towards routine frailty assessment and a whole pathway approach. Anaesthesia 2024; 79:797-800. [PMID: 38775328 DOI: 10.1111/anae.16264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2024] [Indexed: 07/16/2024]
Affiliation(s)
- Rose S Penfold
- Department of Ageing and Health, Usher Institute, University of Edinburgh and Advanced Care Research Centre, University of Edinburgh, Scotland, UK
| | - Adam Hunt
- Research Department of Targeted Intervention, University College London, London, UK
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26
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Zhang L, Sun Y, Sui X, Zhang J, Zhao J, Zhou R, Xu W, Yin C, He Z, Sun Y, Liu C, Song A, Han F. Hypocapnia is associated with increased in-hospital mortality and 1 year mortality in acute heart failure patients. ESC Heart Fail 2024; 11:2138-2147. [PMID: 38600875 PMCID: PMC11287307 DOI: 10.1002/ehf2.14763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 02/29/2024] [Accepted: 03/06/2024] [Indexed: 04/12/2024] Open
Abstract
AIMS Both hypercapnia and hypocapnia are common in patients with acute heart failure (AHF), but the association between partial pressure of arterial carbon dioxide (PaCO2) and AHF prognosis remains unclear. The objective of this study was to investigate the connection between PaCO2 within 24 h after admission to the intensive care unit (ICU) and mortality during hospitalization and at 1 year in AHF patients. METHODS AND RESULTS AHF patients were enrolled from the Medical Information Mart for Intensive Care IV database. The patients were divided into three groups by PaCO2 values of <35, 35-45, and >45 mmHg. The primary outcome was to investigate the connection between PaCO2 and in-hospital mortality and 1 year mortality in AHF patients. The secondary outcome was to assess the prediction value of PaCO2 in predicting in-hospital mortality and 1 year mortality in AHF patients. A total of 2374 patients were included in this study, including 457 patients in the PaCO2 < 35 mmHg group, 1072 patients in the PaCO2 = 35-45 mmHg group, and 845 patients in the PaCO2 > 45 mmHg group. The in-hospital mortality was 19.5%, and the 1 year mortality was 23.9% in the PaCO2 < 35 mmHg group. Multivariate logistic regression analysis showed that the PaCO2 < 35 mmHg group was associated with an increased risk of in-hospital mortality [hazard ratio (HR) 1.398, 95% confidence interval (CI) 1.039-1.882, P = 0.027] and 1 year mortality (HR 1.327, 95% CI 1.020-1.728, P = 0.035) than the PaCO2 = 35-45 mmHg group. The PaCO2 > 45 mmHg group was associated with an increased risk of in-hospital mortality (HR 1.387, 95% CI 1.050-1.832, P = 0.021); the 1 year mortality showed no significant difference (HR 1.286, 95% CI 0.995-1.662, P = 0.055) compared with the PaCO2 = 35-45 mmHg group. The Kaplan-Meier survival curves showed that the PaCO2 < 35 mmHg group had a significantly lower 1 year survival rate. The area under the receiver operating characteristic curve for predicting in-hospital mortality was 0.591 (95% CI 0.526-0.656), and the 1 year mortality was 0.566 (95% CI 0.505-0.627) in the PaCO2 < 35 mmHg group. CONCLUSIONS In AHF patients, hypocapnia within 24 h after admission to the ICU was associated with increased in-hospital mortality and 1 year mortality. However, the increase in 1 year mortality may be influenced by hospitalization mortality. Hypercapnia was associated with increased in-hospital mortality.
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Affiliation(s)
- Lei Zhang
- Department of AnesthesiologyHarbin Medical University Cancer HospitalHarbinChina
| | - Yiwu Sun
- Department of AnesthesiologyDazhou Central HospitalDazhouChina
| | - Xin Sui
- Department of AnesthesiologyHarbin Medical University Cancer HospitalHarbinChina
| | - Jian Zhang
- Department of AnesthesiologyHarbin Medical University Cancer HospitalHarbinChina
| | - Jingshun Zhao
- Department of AnesthesiologyHarbin Medical University Cancer HospitalHarbinChina
| | - Runfeng Zhou
- Department of AnesthesiologyHarbin Medical University Cancer HospitalHarbinChina
| | - Wenjia Xu
- Department of AnesthesiologyHarbin Medical University Cancer HospitalHarbinChina
| | - Chengke Yin
- Department of AnesthesiologyHarbin Medical University Cancer HospitalHarbinChina
| | - Zhaoyi He
- Department of AnesthesiologyHarbin Medical University Cancer HospitalHarbinChina
| | - Yufei Sun
- Department of AnesthesiologyHarbin Medical University Cancer HospitalHarbinChina
| | - Chang Liu
- Department of AnesthesiologyHarbin Medical University Cancer HospitalHarbinChina
| | - Ailing Song
- Department of AnesthesiologyShanghai Jiao Tong University First People's Hospital (Shanghai General Hospital)ShanghaiChina
| | - Fei Han
- Department of AnesthesiologyHarbin Medical University Cancer HospitalHarbinChina
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27
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Flanagan T, Mercer K, Johnson PN, Miller J, Yousaf FS, Fuller JA. Ketamine Use in Adult and Pediatric Patients Receiving Extracorporeal Membrane Oxygenation (ECMO): A Systematic Review. J Pharm Pract 2024; 37:985-994. [PMID: 37670605 DOI: 10.1177/08971900231198928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
Background: Analgesia and sedation are often critical elements of therapy for patients undergoing extracorporeal membrane oxygenation (ECMO). Aside from potential drug-drug interactions, the PK changes associated with ECMO make appropriate analgosedative selection challenging. Ketamine is less lipophilic and has lower protein binding than alternative agents, and may be less impacted by the PK changes during ECMO. Objective: To systematically identify all instances of ketamine use during ECMO support in the literature to elucidate associated efficacy and safety outcomes and prevalence of use, as well as commonly used dosing strategies and pharmacokinetic data. Methods: Web of Science, Cochrane Library, Scopus, Ovid MEDLINE, PubMed, and OVID Embase were searched through 02/2023 using keywords ketamine and ECMO or extracorporal life support (ECLS). Case reports, case series, and studies were included that had (1) original data, (2) included patients that were on ECMO and continuous infusion ketamine, and (3) reported pertinent ketamine related clinical endpoints or prevalence of use. Results: Of the 307 articles screened, 25 were identified as relevant and 11 met our inclusion criteria. Heterogeneity of patient population, ketamine indication, reported outcomes, and reported safety endpoints were identified in the included articles. Commonly reported information includes indications, pharmacokinetics, dosing, adverse effects and use in pediatrics for ketamine, and suspected opioid sparing effect. Conclusion: Our review has found a lack of consistency in reporting and results in adult and pediatric patients. Increased consistency in reporting and larger studies are required to increase our knowledge of ketamine use in both the adult and pediatric patient population.
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Affiliation(s)
- Trenton Flanagan
- Department of Pharmacy: Clinical and Administrative Sciences, College of Pharmacy, The University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Kevin Mercer
- Department of Pharmacy, Memorial Hermann-Texas West Hospital, Houston, TX, USA
| | - Peter N Johnson
- Department of Pharmacy: Clinical and Administrative Sciences, College of Pharmacy, The University of Oklahoma Health Science Center, Oklahoma City, OK, USA
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Jamie Miller
- Department of Pharmacy: Clinical and Administrative Sciences, College of Pharmacy, The University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | | | - Jordan A Fuller
- Department of Pharmacy: Clinical and Administrative Sciences, College of Pharmacy, The University of Oklahoma Health Science Center, Oklahoma City, OK, USA
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28
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Bai W, Ge H, Han H, Xu J, Qin L. Association of frailty and sarcopenia with short-term mortality in older critically ill patients. J Nutr Health Aging 2024; 28:100321. [PMID: 39033576 DOI: 10.1016/j.jnha.2024.100321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 07/07/2024] [Accepted: 07/15/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND There is still no study on the use of the SARC-CalF questionnaire for older critically ill patients. Moreover, there is limited evidence on whether a combination of sarcopenia and frailty can provide incremental improvements in risk stratification for older critically ill patients. METHODS A total of 653 patients older than 60 years were recruited. We used the clinical frailty scale (CFS) and SARC-CalF questionnaire to assess the frailty status and sarcopenia risk, respectively, of older patients shortly after admission to the ICU. The effect of frailty and sarcopenia risk on ICU mortality and 30-day mortality was evaluated. RESULTS A total of 147 (22.5%) patients died in the ICU, and 187 (28.6%) patients died within 30 days after ICU admission. The CFS score was associated with increased ICU mortality [per 1-score increase: odds ratio (OR) = 1.222, 95% confidential interval (CI): 1.003-1.489] and 30-day mortality (per 1-score increase: OR = 1.307, 95% CI: 1.079-1.583). The SARC-CalF score was also associated with increased ICU mortality (per 1-score increase: OR = 1.204, 95% CI: 1.120-1.294) and 30-day mortality (per 1-score increase: OR = 1.247, 95% CI: 1.163-1.337). The addition of the CFS + SARC-CalF score to Acute Physiology and Chronic Health Evaluation (APACHE) II improved discrimination and reclassified ICU and 30-day mortality risk. CONCLUSIONS Sarcopenia risk assessed by the SARC-CalF questionnaire provided independent prognostic information for older critically ill patients. A combination of sarcopenia and frailty improved the prediction of mortality for older critically ill patients and thus might be useful in the clinical decision-making process.
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Affiliation(s)
- Weimin Bai
- Department of Emergency, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, No.7 Weiwu Road, Jinshui District, Zhengzhou 463599, China
| | - Hongbo Ge
- Department of Ultrasound, The People's Hospital of Danyang, Danyang Hospital of Nantong University, Danyang, Jiangsu 212300, China
| | - Han Han
- Department of Emergency, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, No.7 Weiwu Road, Jinshui District, Zhengzhou 463599, China
| | - Juan Xu
- Department of General Surgery, Affiliated Xiaoshan Hospital, Hangzhou Normal University, No.728 Yucai Road, Xiaoshan District, Hangzhou 311202, China.
| | - Lijie Qin
- Department of Emergency, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, No.7 Weiwu Road, Jinshui District, Zhengzhou 463599, China.
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Leonny S, Bowra J, Davis RA, Zuleta N, Hansen K, Large R, Yeung J. Review article: Telehealth in Emergency Medicine in Australasia: Advantages and barriers. Emerg Med Australas 2024; 36:498-504. [PMID: 38649791 DOI: 10.1111/1742-6723.14411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/15/2024] [Accepted: 03/29/2024] [Indexed: 04/25/2024]
Abstract
The COVID-19 pandemic catapulted Telehealth to the forefront of Emergency Medicine (EM) as an alternative way of assessing and managing patients. This challenged the traditional idea that EM can only be practised within brick-and-mortar EDs. Many Emergency Physicians may find the idea of practising Telehealth in Emergency Medicine (TEM) confronting, particularly in the absence of training and clear practice guidelines. The purpose of the present paper is to describe the current use of TEM in Australasia, and outline the advantages and barriers in adopting this practice domain.
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Affiliation(s)
- Sheravika Leonny
- My Emergency Doctor, Sydney, New South Wales, Australia
- Peninsula Health, Melbourne, Victoria, Australia
| | - Justin Bowra
- My Emergency Doctor, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Rebecca A Davis
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- RPA Virtual Hospital, Sydney, New South Wales, Australia
| | - Natalia Zuleta
- WA Country Health Service, Perth, Western Australia, Australia
| | - Kim Hansen
- Virtual Emergency Department, Metro North, Brisbane, Queensland, Australia
- Critical Care, Women's and Children's Service Line, Redcliffe Hospital, Redcliffe, Queensland, Australia
| | - Ruth Large
- New Zealand Telehealth Leadership Group, Christchurch, New Zealand
- Whakarongorau Aotearoa//New Zealand Telehealth Services, Auckland, New Zealand
| | - Justin Yeung
- WA Country Health Service, Perth, Western Australia, Australia
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McDougall G, Loubani O. Interfacility transfer of the critically ill: Transfer status does not influence survival. J Crit Care 2024; 82:154813. [PMID: 38636357 DOI: 10.1016/j.jcrc.2024.154813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 04/05/2024] [Accepted: 04/08/2024] [Indexed: 04/20/2024]
Abstract
PURPOSE To estimate differences in case-mix adjusted hospital mortality between adult ICU patients who are transferred during their ICU-stay and those who are not. METHODS 19,260 visits to 12 ICUs in Nova Scotia (NS), Canada April 2018-September 2023 were analyzed. Data were obtained from the NS Provincial ICU database. Generalized additive models (GAMs) were used to estimate differences in case-mix adjusted hospital mortality between patients who underwent transfer and those who did not. RESULTS 1040/19,260 (5%) ICU visits involved interfacility-transfer. No difference in hospital mortality was identified between transferred and non-transferred patients by GAM (OR, 0.99, 95% CI, 0.82 to 1.19; p = 0.91). No mortality difference was observed between patients undergoing a single transfer versus multiple (OR, 0.87; 95% CI, 0.45 to -1.69; p = 0.68). A GAM including the categories no transfer, one transfer, and multiple transfers identified a difference in hospital mortality for patients that underwent multiple transfers compared to non-transferred patients (OR, 0.68; 95% CI, 0.46 to 1.00, p = 0.05), but no difference was identified in a post-hoc matched cohort sensitivity analysis (OR, 0.68; 95% CI, 0.46 to 1.01, p = 0.05). CONCLUSION The transfer of critically ill patients between ICUs in Nova Scotia did not impact case-mix adjusted hospital mortality.
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Affiliation(s)
- Garrett McDougall
- Department of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Osama Loubani
- Department of Critical Care, Dalhousie University, Halifax, NS, Canada.
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Wang P, Lu M, Huang Y, Sun L, Han Z. Development of a prognostic nomogram for patients underwent extracorporeal circulation auxiliary to open cardiac surgery on hospital mortality: a retrospective cohort study. J Thorac Dis 2024; 16:4174-4185. [PMID: 39144295 PMCID: PMC11320247 DOI: 10.21037/jtd-24-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 05/17/2024] [Indexed: 08/16/2024]
Abstract
Background Extracorporeal circulation auxiliary to open cardiac surgery (ECAOCS) is one of the most complex surgical procedures and carries a very high risk of death. We developed a nomogram from a retrospective study to predict the risk of death during patient hospitalization. Methods All clinical data were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. We extracted clinical variables for the first 24 hours after admission to the intensive care unit (ICU) in a total of 880 patients who underwent ECAOCS. All patients were randomly divided into training and validation cohort in a ratio of 7:3. All variables included in the study were subjected to univariate logistic regression analysis. In order to prevent overfitting and to address the problem of severe covariance, all factors with P<0.05 in the univariate logistic regression analysis were analyzed using the least absolute shrinkage and selection operator (LASSO) regression. A multivariate logistic regression model was developed based on the factors output from the LASSO regression and a nomogram was plotted. The receiver operating characteristic (ROC) curve was constructed and the area under the curve (AUC) was calculated in training and validation cohort. Finally, the evaluation of the model was performed by calibration curves and Hosmer-Lemeshow goodness-of-fit test (HL test) and decision curve analysis (DCA) was performed. Results Indicators included in the nomogram were anion gap (AG), central venous pressure (CVP), glucose, creatinine (Cr), prothrombin time (PT), activated partial thromboplastin time (APTT), bicarbonate ion (HCO3 -), cerebrovascular disease (CVD), peripheral vascular disease (PVD), and acute myocardial infarction (AMI). Conclusions Our study developed a model for predicting postoperative hospital mortality in patients underwent ECAOCS by incorporating AG, CVP, glucose, Cr, APTT, HCO3 -, CVD, AMI, and PVD from the first 24 hours after admission to the ICU. Keywords Extracorporeal circulation; cardiac surgery; intensive care; nomogram; prediction model.
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Affiliation(s)
- Peihe Wang
- Department of Cardiovascular Surgery, Peking University Shenzhen Hospital, Shenzhen, China
- Shantou University Medical College, Shantou, China
| | - Meiling Lu
- Department of Cardiovascular Surgery, Peking University Shenzhen Hospital, Shenzhen, China
| | - Yu Huang
- Department of Cardiovascular Surgery, Peking University Shenzhen Hospital, Shenzhen, China
| | - Lu Sun
- Department of Cardiovascular Surgery, Peking University Shenzhen Hospital, Shenzhen, China
| | - Zhen Han
- Department of Cardiovascular Surgery, Peking University Shenzhen Hospital, Shenzhen, China
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Jamal A, Abraham J, Neeliyara AM, Saji A. Effect of Nutritional Support on Energy Balance and Its Clinical Outcome in ICU [Intensive Care Unit] Patients. Hosp Top 2024:1-8. [PMID: 39069954 DOI: 10.1080/00185868.2024.2383908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
Critical care is the specialized treatment provided to patients in intensive care units who are severely ill and need extensive care and close monitoring. Hence the present study was undertaken. A total of hundred samples were collected exclusively on those who stayed a minimum of five days in Intensive Care Unit from two reputed Multispecialty Tertiary Hospitals from Kerala, India. APACHE II scoring system, Day World Wide's ICU Questionnaire and Glasgow Coma Scale were adopted to collect patient's data such as personal details, demographic data, medical history, bio-physical parameters, bio- chemical parameters, feeding techniques, time of feeding and nutritional requirements. Admission to Medical ICU were about 43% with respiratory failure, sepsis and other infections, 22% were admitted with neurological diseases and 35% were nephrology patient. It is evident that about 79% were suffering from anorexia. Comparing the administration of exclusive commercial feed to commercial plus kitchen feed, it was observed that patients fed with the latter experienced increased abdominal pain (21%) and vomiting (17%). Diarrhea was more common in patients fed with commercial formula (12%), while constipation was higher in patients fed with kitchen feed (19%). There is no conclusive evidence favoring either exclusive commercial feed or kitchen plus commercial feed. A small percentage (7%) of patients had a mortality rate exceeding 80%. Positive outcomes were observed in critically ill patients through the enteral feeding system, with no significant difference between exclusive commercial feed and kitchen plus commercial feed.
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Affiliation(s)
- Amina Jamal
- Department of Home Science, St Joseph's College for Women, Alappuzha, India
| | - Jiby Abraham
- Department of Home Science, St Joseph's College for Women, Alappuzha, India
| | - Anju M Neeliyara
- Department of Home Science, St Joseph's College for Women, Alappuzha, India
| | - Akshara Saji
- Department of Home Science, St Joseph's College for Women, Alappuzha, India
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Misirocchi F, Quintard H, Seeck M, De Stefano P. Metabolic alkalosis: a new red flag in status epilepticus. J Neurol 2024:10.1007/s00415-024-12603-x. [PMID: 39066791 DOI: 10.1007/s00415-024-12603-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 07/19/2024] [Accepted: 07/20/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Status epilepticus (SE) is a heterogeneous neurological emergency with significant variability in prognosis, influenced by underlying disease and pathophysiological context. Acid-base disturbances are common in critically ill patients, yet their distribution and impact in SE patients remain poorly understood. METHODS This was an observational cohort study including non-hypoxic SE patients with available blood gas analysis within the first 24 h of SE, treated at the University Hospital of Geneva, Switzerland between 2015 and 2023. Acid-base disturbances were classified using the Henderson-Hasselbalch equation, with prevalent metabolic alkalosis confirmed through the Stewart approach. Primary outcomes were in-hospital mortality, Glasgow Outcome Scale (GOS) at discharge, and return to premorbid neurologic function. FINDINGS Among 540 SE patients, 365 were included. Half of patients exhibited acid-base disturbances within the initial 24 h of SE, with metabolic and respiratory acidosis being the most prevalent, though not prognostically significant. After correction for possible confounders, metabolic alkalosis (6%) was associated with increased in-hospital mortality (P = 0.011; OR = 4.87, 95% CI = 1.29-7.84), worse GOS (P = 0.012; OR = 3.18, 95% CI = 1.29-7.84), and reduced likelihood of returning to premorbid function (P = 0.017; OR = 3.30, CI95% = 1.24-8.80). Following the Stewart approach, 9% of patients had predominant metabolic alkalosis, associated with worse GOS (P = 0.005; OR:3.37, 95%CI = 1.45-7.82), and reduced chance of returning to baseline (P = 0.012; OR = 3.29, CI95% = 1.30-8.32). Metabolic alkalosis was related to hypoalbuminemia and lower serum potassium. CONCLUSION Metabolic alkalosis strongly predicts mortality and adverse functional outcome in SE patients. Prospective studies should assess whether early detection and correction of metabolic alkalosis and related electrolyte imbalances can improve SE prognosis.
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Affiliation(s)
- Francesco Misirocchi
- Unit of Neurology, Department of Medicine and Surgery, University of Parma, Parma, Italy
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Hervé Quintard
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
- Medical Faculty of the University of Geneva, Geneva, Switzerland
| | - Margitta Seeck
- Medical Faculty of the University of Geneva, Geneva, Switzerland
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
| | - Pia De Stefano
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland.
- Medical Faculty of the University of Geneva, Geneva, Switzerland.
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland.
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Lane TJ, Smith CL, Gao CX, Ikin JF, Xu R, Carroll MTC, Nehme E, Abramson MJ, Guo Y. Long-term effects of a coalmine fire on hospital and ambulance use: An interrupted time series study. ENVIRONMENTAL RESEARCH 2024; 261:119693. [PMID: 39068973 DOI: 10.1016/j.envres.2024.119693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 07/12/2024] [Accepted: 07/25/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND In 2014, the Hazelwood coalmine fire in regional Victoria, Australia shrouded nearby communities in smoke for six weeks. Prior investigations identified substantial adverse effects, including increases in the use of health services. In this study, we examined the effects on hospital and ambulance use in the eight years following the fire. METHODS Using Victorian hospital (Jan 2009-Jun 2022) and ambulance (Jan 2013-Dec 2021) data, we conducted an interrupted time series of changes to the rate of hospital admissions, emergency presentations, and ambulance attendances. A categorical exposure model compared two locations, most-exposed Morwell and less-exposed Latrobe Valley, to the rest of regional Victoria. A continuous exposure model used spatial estimates of fire-related PM2.5. Analyses were stratified by sex, age group (<65/65+ years), and condition (cardiovascular, respiratory, mental health, injury). RESULTS There were small but significant increases in overall hospital admissions and emergency presentations across all analyses, but little evidence of change in overall ambulance attendances. Effects varied considerably by condition, with the biggest relative increases observed among hospital admissions for mental health conditions and injuries. While cardiovascular-related hospital admissions and emergency presentations increased post-fire, ambulance attendances decreased. CONCLUSIONS Our findings suggest the Hazelwood coalmine fire likely increased hospital usage. However, it is unclear whether this was due to the direct effects of smoke exposure on health, or the disruptive socioeconomic and behavioural impacts of an environmental disaster that affected how communities engaged with various health services.
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Affiliation(s)
- Tyler J Lane
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Catherine L Smith
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Caroline X Gao
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Orygen, Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Jillian F Ikin
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rongbin Xu
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Matthew T C Carroll
- Monash Rural Health Churchill, Monash University, Churchill, Victoria, Australia
| | - Emily Nehme
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Centre for Research and Evaluation, Ambulance Victoria, Australia
| | - Michael J Abramson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Yuming Guo
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Fang CS, Tu YK, Chou FH, Fang CJ, Chang SL. Effect of inhaled aromatherapy on sleep quality in critically ill patients: A systematic review and network meta-analysis. J Clin Nurs 2024. [PMID: 39041491 DOI: 10.1111/jocn.17368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/03/2023] [Accepted: 07/04/2024] [Indexed: 07/24/2024]
Abstract
AIM This study aimed to compare the effect of inhaled aromatherapy using various essential oils on the sleep quality of critically ill patients. BACKGROUND Inhalation of essential oils significantly promotes the physiological and psychological health of patients in intensive care units (ICUs). However, research identifying and ranking the effects of different essential oils on the sleep quality of critically ill patients is lacking. DESIGN This study followed the PRISMA Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-Analyses of Health Care Interventions (PRISMA-NMA) guidelines. METHODS A comprehensive search of five databases (Embase, MEDLINE, the Cochrane Library, CINAHL and PsycINFO) was conducted from their inception to March 15, 2023 (with an additional eligible study included dated August 14, 2023). Google Scholar was used as a supplementary method. Frequentist NMA was used to determine the effects of various essential oils. Certainty of evidence (CoE) was assessed using Confidence in Network Meta-Analysis (CINeMA). RESULTS A total of 11 trials involving 690 critically ill patients were included in the analysis. The NMA of inhaled aromatherapy revealed that the combination of lavender, Matricaria recutita, and neroli essential oils (ratio 6:2:0.5) resulted in the most significant improvement in sleep quality compared to usual care, followed by Rosa damascene, peppermint, Citrus aurantium, pure sunflower oil and lavender oil alone. The overall CoE for the results was rated as low. CONCLUSIONS The results of this study indicate that a combination of lavender, Matricaria recutita and neroli essential oils significantly positively affected sleep quality among critically ill patients. Despite the low quality of evidence, inhaled aromatherapy is non-invasive and easy to use. RELEVANCE TO CLINICAL PRACTICE Inhaled aromatherapy can effectively improve sleep quality among critically ill patients. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution applies to this work. STUDY REGISTRATION The study protocol was registered to the PROSPERO International Prospective Register of Systematic Reviews (protocol number CRD42023433194).
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Affiliation(s)
- Chiu-Shu Fang
- Department of Nursing, Chi-Mei Medical Center, Tainan, Yongkang District, Taiwan
| | - Yu-Kang Tu
- Insitute of Health Data Analytics and Statistics, College of Public Health, National Taiwan University, Taipei, Taiwan
- Center of Health Data Research, National Taiwan University Hospital, Taipei, Taiwan
- Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
| | - Fan-Hao Chou
- School of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ching-Ju Fang
- Department of Secretariat, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Medical Library, National Cheng Kung University, Tainan, Taiwan
| | - Shih-Lun Chang
- Department of Otorhinolaryngology, Chi-Mei Medical Center, Tainan, Yongkang District, Taiwan
- Department of pet Care and Groomimg, Chung Hwa University of Medical Technology, Tainan, Taiwan
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Lu Y, Li W, Qi S, Cheng K, Wu H. Mapping knowledge structure and emerging trends of extracorporeal membrane oxygenation for acute respiratory distress syndrome: a bibliometric and visualized study. Front Med (Lausanne) 2024; 11:1365864. [PMID: 39086955 PMCID: PMC11288878 DOI: 10.3389/fmed.2024.1365864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 06/25/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction With the discovery of extracorporeal membrane oxygenation (ECMO), it is considered as a valuable tool for supporting the treatment of severe acute respiratory distress syndrome (ARDS). It has gained increasing attention, particularly during the COVID-19 epidemic. However, to date, no relevant bibliometric research on the association between ECMO and ARDS (ECMO-ARDS) has been reported. Our study aimed to summarize the knowledge structure and research focus of ECMO-ARDS through a bibliometric analysis. Method Publications related to ECMO-ARDS from 2000 to 2022 were obtained from the Web of Science Core Collection (WoSCC). Research data underwent bibliometric and visual analysis by using CiteSpace, VOSviewer, and one online analysis platform. By analyzing the countries, institutions, journals, authors, the geographic distribution of research contributions as well as the leading institutions and researchers in this field were identified. Additionally, prominent journals and highly cited publications were highlighted, indicating their influence and significance in the field. Moreover, the co-citation references and co-occurring keywords provided valuable information on the major research topics, trends, and potential emerging frontiers. Results A total of 1,565 publications from 60 countries/regions were retrieved. The annual publication number over time revealed exponential growth trends (R2 = 0.9511). The United States was dominant in ECMO-ARDS research, whereas the Univ Toronto was most productive institution. Prof Combes A published the most publications in this area. ASAIO Journal and Intensive Care Medicine were the most active and co-cited journals, respectively. Reference co-citation analysis showed that current research focus has shifted to COVID-related ARDS, multi-center studies, as well as prone positioning. Apart from the keywords "ECMO" and "ARDS", other keywords appearing at high frequency in the research field were "COVID-19", "mechanical ventilation", "extracorporeal life support", "respiratory failure", "veno-venous ECMO", "SARS-CoV-2", "outcome". Among them, keywords like "mortality", "veno-venous ECMO", "epidemiology", "obesity", "coagulopathy", "lung ultrasound", "inhalation injury", "noninvasive ventilation", "diagnosis", "heparin", "cytokine storm" has received growing interest in current research and also has the potential to continue to become research hotspots in the near future. Conclusion This bibliometric analysis offers a comprehensive understanding of the current state of ECMO-ARDS research and can serve as a valuable resource for researchers, policymakers, and stakeholders in exploring future research directions and fostering collaborations in this critical field.
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Affiliation(s)
- Yanqiu Lu
- Department of Intensive Care Unit, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Wanqing Li
- Department of Operating Room, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Shaoyan Qi
- Department of Intensive Care Unit, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Kunming Cheng
- Department of Intensive Care Unit, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Haiyang Wu
- Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Shandera WX. COVID-19 ethics: unique aspects and a review as of early 2024. Monash Bioeth Rev 2024:10.1007/s40592-024-00199-x. [PMID: 39003388 DOI: 10.1007/s40592-024-00199-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2024] [Indexed: 07/15/2024]
Abstract
COVID-19 presents a variety of ethical challenges in a set of arenas, arenas not always considered in past pandemics. These challenges include issues related to autonomy, distributive ethics, and the establishment of policies of equity and justice. Methods are a literature review based on regular editing of an online textbook during the COVID-19 outbreak and a literature review using key ethical terms. Patients are confronted with new issues related to autonomy. Providers need to expand their concepts of ethical issues to include decisions based on proportionality and public health ethics. The public health sector needs to assess the beneficence of alternative modes of disease control. The research community needs to redefine the concept of informed consent in emergent conditions. All elements of the medical spectrum-physicians, scientists, and the community-at-large including the pharmaceutical industry-need to consider the multifaceted methods for preventing future pandemics. This will require giving particular emphasis to public health funding and ending the documented discrimination that exists in the provision of proven therapies. The developing world is especially at risk for most of the ethical issues, especially those related to equity and justice. The ethical issues associated with the COVID-19 outbreak are not unique but provide a diverse set of issues that apply to patients, providers, social groups, and investigators. The further study of such issues can help with preventing future outbreaks.
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Santangelo E, Wozniak H, Herridge MS. Meeting complex multidimensional needs in older patients and their families during and beyond critical illness. Curr Opin Crit Care 2024:00075198-990000000-00198. [PMID: 39150056 DOI: 10.1097/mcc.0000000000001188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
PURPOSE OF REVIEW To highlight the emerging crisis of critically ill elderly patients and review the unique burden of multidimensional morbidity faced by these patients and caregivers and potential interventions. RECENT FINDINGS Physical, psychological, and cognitive sequelae after critical illness are frequent, durable, and robust across the international ICU outcome literature. Elderly patients are more vulnerable to the multisystem sequelae of critical illness and its treatment and the resultant multidimensional morbidity may be profound, chronic, and significantly affect functional independence, transition to the community, and quality of life for patients and families. Recent data reinforce the importance of baseline functional status, health trajectory, and chronic illness as key determinants of long-term functional disability after ICU. These risks are even more pronounced in older patients. SUMMARY The current article is an overview of the outcomes of older survivors of critical illness, putative interventions to mitigate the long-term morbidity of patients, and the consequences for families and caregivers. A multimodal longitudinal approach designed to follow patients for one or more years may foster a better understanding of multidimensional morbidity faced by vulnerable older patients and families and provides a detailed understanding of recovery trajectories in this unique population to optimize outcome, goals of care directives, and ongoing informed consent to ICU treatment.
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Affiliation(s)
- Erminio Santangelo
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Hannah Wozniak
- Division of Critical Care, Department of Acute Medicine, Geneva University Hospitals, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
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Pashmforosh M, Rajabi Vardanjani H, Khorsandi L, Shariati S, Mohtadi S, Khodayar MJ. Carvacrol protects rats against bleomycin-induced lung oxidative stress, inflammation, and fibrosis. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024:10.1007/s00210-024-03273-7. [PMID: 38976045 DOI: 10.1007/s00210-024-03273-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 07/01/2024] [Indexed: 07/09/2024]
Abstract
The main objective of this study was to investigate the potential efficacy of carvacrol (CAR) in mitigating bleomycin (BLM)-induced pulmonary fibrosis (PF). Sixty-six male Wistar rats were assigned into two main groups of 7 and 21 days. They were divided into the subgroups of control, BLM, CAR 80 (only for the 21-day group), and CAR treatment groups. The CAR treatment groups received CAR (20, 40, and 80 mg/kg, orally) for 7 or 21 days after an instillation of BLM (5 mg/kg, intratracheally). Results indicated that BLM significantly increased total cell count in bronchoalveolar lavage fluid and the percentages of neutrophils and lymphocytes, and reduced the percentage of macrophages. CAR dose-dependently decreased total cell count and the percentage of neutrophils and lymphocytes. CAR significantly reduced thiobarbituric acid reactive substances and hydroxyproline levels and elevated the total thiol level and catalase, superoxide dismutase, and glutathione peroxidase activities in BLM-exposed rats. Furthermore, CAR decreased the transforming growth factor-β1, connective transforming growth factor, and tumor necrosis factor-α on days 7 and 21. BLM increased interferon-γ on day 7 but decreased its level on day 21. However, CAR reversed interferon-γ levels on days 7 and 21. Based on histopathological findings, BLM induced inflammation on days 7 and 21, but for induction of fibrosis, 21-day study showed more fibrotic injuries than the 7-day group. CAR showed the improvement of fibrotic injuries. The effect of CAR against BLM-induced pulmonary fibrosis is possibly due to its antioxidant, anti-inflammatory, and antifibrotic activity.
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Affiliation(s)
| | - Hossein Rajabi Vardanjani
- Department of Pharmacology, Faculty of Pharmacy, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Layasadat Khorsandi
- Cellular and Molecular Research Center, Medical Basic Sciences Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Saeedeh Shariati
- Student Research Committee, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Department of Toxicology, Faculty of Pharmacy, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Toxicology Research Center, Medical Basic Sciences Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Shokooh Mohtadi
- Student Research Committee, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Department of Toxicology, Faculty of Pharmacy, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Toxicology Research Center, Medical Basic Sciences Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohammad Javad Khodayar
- Department of Toxicology, Faculty of Pharmacy, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
- Toxicology Research Center, Medical Basic Sciences Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
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Edinger F, Holtz L, Schmidt G, Schneck E, Zajonz T, Sander M, Koch C. New Insights into Hepatic and Intestinal Microcirculation and Pulmonary Inflammation in a Model of Septic Shock and Veno-Arterial Extracorporeal Membrane Oxygenation in the Rat. Int J Mol Sci 2024; 25:7421. [PMID: 39000529 PMCID: PMC11242878 DOI: 10.3390/ijms25137421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 07/02/2024] [Accepted: 07/04/2024] [Indexed: 07/16/2024] Open
Abstract
Despite significant efforts toward improving therapy for septic shock, mortality remains high. Applying veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO) in this context remains controversial. Since the cannulation of the femoral artery for V-A ECMO return leads to lower body hyperoxia, this study investigated the impact of V-A ECMO therapy on the intestinal and hepatic microcirculation during septic shock in a rodent model. Thirty male Lewis rats were randomly assigned to receive V-A ECMO therapy with low (60 mL/kg/min) or high (90 mL/kg/min) blood flow or a sham procedure. Hemodynamic data were collected through a pressure-volume catheter in the left ventricle and a catheter in the lateral tail artery. Septic shock was induced by intravenous administration of lipopolysaccharide (1 mg/kg). The rats received lung-protective ventilation during V-A ECMO therapy. The hepatic and intestinal microcirculation was measured by micro-lightguide spectrophotometry after median laparotomy for two hours. Systemic and pulmonary inflammation was detected via enzyme-linked immunosorbent assays (ELISA) of the plasma and bronchoalveolar lavage (BAL), respectively, measuring tumor necrosis factor-alpha (TNF-α), interleukins 6 (IL-6) and 10 (IL-10), and C-X-C motif ligands 2 (CXCL2) and 5 (CXCL5). Oxygen saturation and relative hemoglobin concentration were reduced in the hepatic and intestinal microcirculation during V-A ECMO therapy, independent of the blood flow rate. Further, rats treated with V-A ECMO therapy also presented elevated systolic, diastolic, and mean arterial blood pressure and increased stroke volume, cardiac output, and left ventricular end-diastolic volume. However, left ventricular end-diastolic pressure was only elevated during high-flow V-A ECMO therapy. Blood gas analysis revealed a dilutional anemia during V-A ECMO therapy. ELISA analysis showed an elevated plasma CXCL2 concentration only during high-flow V-A ECMO therapy and elevated BAL CXCL2 and CXCL5 concentrations only during low-flow V-A ECMO therapy. Rats undergoing V-A ECMO therapy exhibited impaired microcirculation of the intestine and liver during septic shock despite increased blood pressure and cardiac output. Increased pulmonary inflammation was detected only during low-flow V-A ECMO therapy in septic shock.
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Affiliation(s)
- Fabian Edinger
- Department of Anesthesiology, Critical Care Medicine and Pain Therapy, University Hospital of Giessen, Justus-Liebig-University, 35392 Giessen, Germany
| | - Lena Holtz
- Department of Anesthesiology, Critical Care Medicine and Pain Therapy, University Hospital of Giessen, Justus-Liebig-University, 35392 Giessen, Germany
| | - Götz Schmidt
- Department of Anesthesiology, Critical Care Medicine and Pain Therapy, University Hospital of Giessen, Justus-Liebig-University, 35392 Giessen, Germany
| | - Emmanuel Schneck
- Department of Anesthesiology, Critical Care Medicine and Pain Therapy, University Hospital of Giessen, Justus-Liebig-University, 35392 Giessen, Germany
| | - Thomas Zajonz
- Department of Anesthesiology, Critical Care Medicine and Pain Therapy, University Hospital of Giessen, Justus-Liebig-University, 35392 Giessen, Germany
| | - Michael Sander
- Department of Anesthesiology, Critical Care Medicine and Pain Therapy, University Hospital of Giessen, Justus-Liebig-University, 35392 Giessen, Germany
| | - Christian Koch
- Department of Anesthesiology, Critical Care Medicine and Pain Therapy, University Hospital of Giessen, Justus-Liebig-University, 35392 Giessen, Germany
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Battaglini D, Kelly TL, Griffee M, Fanning J, Premraj L, Whitman G, Porto DB, Arora R, Thomson D, Pelosi P, White NM, Bassi GL, Suen J, Fraser JF, Robba C, Cho SM. Stroke in critically ill patients with respiratory failure due to COVID-19: Disparities between low-middle and high-income countries. Heart Lung 2024; 68:131-144. [PMID: 38968643 DOI: 10.1016/j.hrtlng.2024.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/18/2024] [Accepted: 06/21/2024] [Indexed: 07/07/2024]
Abstract
PURPOSE We aimed to compare the incidence of stroke in low-and middle-income countries (LMICs) versus high-income countries (HICs) in critically ill patients with COVID-19 and its impact on in-hospital mortality. METHODS International observational study conducted in 43 countries. Stroke and mortality incidence rates and rate ratios (IRR) were calculated per admitted days using Poisson regression. Inverse probability weighting (IPW) was used to address the HICs vs. LMICs imbalance for confounders. RESULTS 23,738 patients [20,511(86.4 %) HICs vs. 3,227(13.6 %) LMICs] were included. The incidence stroke/1000 admitted-days was 35.7 (95 %CI = 28.4-44.9) LMICs and 17.6 (95 %CI = 15.8-19.7) HICs; ischemic 9.47 (95 %CI = 6.57-13.7) LMICs, 1.97 (95 %CI = 1.53, 2.55) HICs; hemorrhagic, 7.18 (95 %CI = 4.73-10.9) LMICs, and 2.52 (95 %CI = 2.00-3.16) HICs; unspecified stroke type 11.6 (95 %CI = 7.75-17.3) LMICs, 8.99 (95 %CI = 7.70-10.5) HICs. In regression with IPW, LMICs vs. HICs had IRR = 1.78 (95 %CI = 1.31-2.42, p < 0.001). Patients from LMICs were more likely to die than those from HICs [43.6% vs 29.2 %; Relative Risk (RR) = 2.59 (95 %CI = 2.29-2.93), p < 0.001)]. Patients with stroke were more likely to die than those without stroke [RR = 1.43 (95 %CI = 1.19-1.72), p < 0.001)]. CONCLUSIONS Stroke incidence was low in HICs and LMICs although the stroke risk was higher in LMICs. Both LMIC status and stroke increased the risk of death. Improving early diagnosis of stroke and redistribution of healthcare resources should be a priority. TRIAL REGISTRATION ACTRN12620000421932 registered on 30/03/2020.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
| | - Thu-Lan Kelly
- Queensland University of Technology, Brisbane, Australia
| | - Matthew Griffee
- Department of Anesthesiology and Perioperative Medicine, University of Utah, Salt Lake City, UT, USA
| | - Jonathon Fanning
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - Lavienraj Premraj
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Griffith University School of Medicine, Gold Coast, Australia
| | - Glenn Whitman
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Diego Bastos Porto
- Faculty of Medicine, Department of Clinical Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Rakesh Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - David Thomson
- Division of Critical Care, University of Cape Town, Cape Town, South Africa
| | - Paolo Pelosi
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Nicole M White
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia; Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Gianluigi Li Bassi
- Queensland University of Technology, Brisbane, Australia; Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia; Institut d'Investigacions Biomediques August Pi i Sunyer, Barcelona, Spain; University of Queensland, Brisbane, Australia; St Andrew's War Memorial Hospital, UnitingCare Hospitals, Brisbane Australia; Wesley Medical Research, Brisbane, Australia
| | - Jacky Suen
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - John F Fraser
- Queensland University of Technology, Brisbane, Australia; Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia; University of Queensland, Brisbane, Australia; St Andrew's War Memorial Hospital, UnitingCare Hospitals, Brisbane Australia; Wesley Medical Research, Brisbane, Australia; School of Medicine, Griffith University, Brisbane, Australia
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Shafiqa N, Aston S, Howard A, Turtle L, Abrams S, Young B, Sherratt F, Alvarez Nishio A, Wilshaw S, Jones AP, Wootton DG. HAP-FAST: a feasibility study incorporating qualitative, mechanistic and costing sub-studies alongside a randomised pilot trial comparing chest x-ray to low-dose CT scan and empirical antibiotics to antibiotics guided by the BIOFIRE® FILM ARRAY® pneumonia plus panel in adults with suspected non-ventilator-associated hospital-cquired pneumonia. BMJ Open 2024; 14:e088490. [PMID: 38964799 PMCID: PMC11227820 DOI: 10.1136/bmjopen-2024-088490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 06/11/2024] [Indexed: 07/06/2024] Open
Abstract
INTRODUCTION Non-ventilator-associated hospital-acquired pneumonia (nv-HAP) is the most common healthcare-associated infection (HCAI), is associated with high mortality and morbidity and places a major burden on healthcare systems. Diagnosis currently relies on chest x-rays to confirm pneumonia and sputum cultures to determine the microbiological cause. This approach leads to over-diagnosis of pneumonia, rarely identifies a causative pathogen and perpetuates unnecessary and imprecise antibiotic use. The HAP-FAST study aims to evaluate the feasibility of a randomised trial to evaluate the clinical impact of low-dose, non-contrast-enhanced thoracic CT scans and rapid molecular sputum analysis using the BIOFIRE® FILMARRAY® pneumonia plus panel (FAPP) for patients suspected with nv-HAP. METHODS AND ANALYSIS The HAP-FAST feasibility study consists of a pilot randomised trial, a qualitative study, a costing analysis and exploratory analyses of clinical samples to investigate the immune-pathophysiology of HAP. Participants are identified and recruited from four acute hospitals in the Northwest of the UK. Using a Research Without Prior Consent model, the pilot trial will recruit 220 adult participants, with or without mental capacity, and with suspected HAP. HAP-FAST is a non-blinded, sequential, multiple assignment, randomised trial with two possible stages of randomisation: first, chest x-ray (CXR) or CT; second, if treated as nv-HAP, FAPP or standard microbiological processing alone (no FAPP). Pathogen-specific antibiotic guidance will be provided for FAPP results. Randomisation uses a web-based platform and followed up for 90 days. The feasibility of a future trial will be determined by assessing trial processes, outcome measures and patient and staff experiences. ETHICS AND DISSEMINATION This study has undergone combined review by the UK NHS Research Ethics Committee and Health Research Authority. Results will be disseminated via peer-reviewed journals, via the funders' website and through a range of media to engage the public. TRIAL REGISTRATION NUMBER NCT05483309.
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Affiliation(s)
- Natalia Shafiqa
- Department of Clinical Infection, Microbiology and Immunology (CIMI), University of Liverpool, Liverpool, UK
- Department of Respiratory Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Stephen Aston
- Tropical and Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Department of Antimicrobial Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Alex Howard
- Department of Antimicrobial Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Lance Turtle
- Department of Clinical Infection, Microbiology and Immunology (CIMI), University of Liverpool, Liverpool, UK
- Tropical and Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- NIHR Health Protection Research Unit for Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK
| | - Simon Abrams
- Department of Clinical Infection, Microbiology and Immunology (CIMI), University of Liverpool, Liverpool, UK
| | - Bridget Young
- Institute of Population Health, Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Frances Sherratt
- Institute of Population Health, Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | | | - Stephanie Wilshaw
- Liverpool Clinical Trials Centre (LCTC), University of Liverpool, Liverpool, UK
| | - Ashley P Jones
- Liverpool Clinical Trials Centre (LCTC), University of Liverpool, Liverpool, UK
| | - Dan G Wootton
- Department of Clinical Infection, Microbiology and Immunology (CIMI), University of Liverpool, Liverpool, UK
- Department of Respiratory Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- NIHR Health Protection Research Unit for Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK
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Ross P, Sheldrake J, Ilic D, Watterson J, Berkovic D, Pilcher D, Udy A, Hodgson CL. An exploration of intensive care nurses' perceptions of workload in providing extracorporeal membrane oxygenation (ECMO) support: A descriptive qualitative study. Aust Crit Care 2024; 37:585-591. [PMID: 38355389 DOI: 10.1016/j.aucc.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 11/16/2023] [Accepted: 12/11/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND There is increasing use of extracorporeal membrane oxygenation (ECMO) in intensive care, where nurses provide the majority of the required ongoing care of cannulas, circuit, and console. Limited evidence currently exists that details nursing perspectives, experiences, and challenges with workload in the provision of ECMO care. OBJECTIVE The objective of this study was to investigate intensive care nurses' perceptions of workload in providing specialist ECMO therapy and care in a high-volume ECMO centre. METHODS The study used a qualitative descriptive methodology through semistructured interviews. Data were analysed using an inductive thematic analysis approach following Braun and Clarke's iterative process. This study was conducted in an intensive care unit within an Australian public, quaternary, university-affiliated hospital, which provides specialist state-wide service for ECMO. FINDINGS Thirty ECMO-specialist trained intensive care nurses were interviewed. This study identified three key themes: (i) opportunity; (ii) knowledge and responsibilities; and (iii) systems and structures impacting on intensive care nurses' workload in providing ECMO supportive therapy. CONCLUSIONS Intensive care nurses require advanced clinical and critical thinking skills. Intensive care nurses are motivated and engaged to learn and acquire ECMO skills and competency as part of their ongoing professional development. Providing bedside ECMO management requires constant monitoring and surveillance from nurses to care for the one of the most critically unwell patient populations in the intensive care unit setting. As such, ECMO nursing services require a suitably trained and educated workforce of intensive care trained nurses. ECMO services provide clinical development opportunities for nurses, increase their scope of practice, and create advanced practice-specialist roles.
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Affiliation(s)
- Paul Ross
- Department of Intensive Care, Alfred Health, Commercial Road, Melbourne, VIC, 3004, Australia; School of Public Health & Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, 3004, VIC, Australia.
| | - Jayne Sheldrake
- Department of Intensive Care, Alfred Health, Commercial Road, Melbourne, VIC, 3004, Australia.
| | - Dragan Ilic
- School of Public Health & Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, 3004, VIC, Australia.
| | - Jason Watterson
- Department of Intensive Care, Frankston Hospital, Peninsula Health, Frankston, VIC, 3199, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health & Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, 3004, VIC, Australia.
| | - Danielle Berkovic
- School of Public Health & Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, 3004, VIC, Australia.
| | - David Pilcher
- Department of Intensive Care, Alfred Health, Commercial Road, Melbourne, VIC, 3004, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health & Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, 3004, VIC, Australia.
| | - Andrew Udy
- Department of Intensive Care, Alfred Health, Commercial Road, Melbourne, VIC, 3004, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health & Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, 3004, VIC, Australia.
| | - Carol L Hodgson
- Department of Intensive Care, Alfred Health, Commercial Road, Melbourne, VIC, 3004, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health & Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, 3004, VIC, Australia.
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Glover G, Metaxa V, Ostermann M. Intensive Care Unit Without Walls. Crit Care Clin 2024; 40:549-560. [PMID: 38796227 DOI: 10.1016/j.ccc.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Critical illness is a continuum with different phases and trajectories. The "Intensive Care Unit (ICU) without walls" concept refers to a model whereby care is adjusted in response to the patient's needs, priorities, and preferences at each stage from detection, escalation, early decision making, treatment and organ support, followed by recovery and rehabilitation, within which all healthcare staff, and the patient are equal partners. The rapid response system incorporates monitoring and alerting tools, a multidisciplinary critical care outreach team and care bundles, supported with education and training, analytical and governance functions, which combine to optimise outcomes of critically ill patients, independent of location.
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Affiliation(s)
- Guy Glover
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital, Denmark Hill, SE5 9RS, London, UK
| | - Marlies Ostermann
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, UK.
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45
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Trivedi JR, Endo T, Sharma A, Fox MP, Slaughter MS, van Berkel VH. Ambulatory Extracorporeal Membrane Oxygenation Use in Patients Listed for Lung Transplant. ASAIO J 2024; 70:625-632. [PMID: 38300884 DOI: 10.1097/mat.0000000000002154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
There has been an increase in the use of extracorporeal membrane oxygenation (ECMO) to bridge critically ill patients to lung transplant (LTX). This study evaluates how ambulatory status on ECMO affected waitlist and post-LTX outcomes. The United Network of Organ Sharing (UNOS) database was queried for patients aged of greater than or equal to 18 years and between 2016 and 2021 to identify pre-LTX patients supported by ECMO. The patients were classified in venous-arterial (VA) ECMO and veno-venous (VV) ECMO cohorts and further classified as ambulatory (AMB) and non-AMB (nAMB). Each cohort was controlled against the non-ECMO patients. Univariate statistical tests, as well as Kaplan-Meier survival curves, were used for analysis. The 90 day waitlist survival was the highest among the non-ECMO group (96%), but both AMB VV and VA groups had superior survival compared to the nAMB group (85% vs. 75%, 78% vs. 65%, p < 0.01). After adjusting for the median lung allocation score (LAS) (88) in the VV ECMO group, the waitlist survival was superior in the AMB VV ECMO compared to those not on ECMO (86% vs. 78%, p > 0.01). The 1 year post-LTX survival between non-ECMO and AMB VV ECMO was comparable (88% vs. 88%, p = 0.66). Ambulating patients or use of physical therapy while on ECMO can help improve lung transplant outcomes.
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Affiliation(s)
- Jaimin R Trivedi
- From the Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky
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Ludwig A, Slota J, Nunes DA, Vranas KC, Kruser JM, Scott KS, Huang R, Johnson JK, Lagu TC, Nadig NR. Interhospital Transfer of Patients With Acute Respiratory Failure in the United States: A Scoping Review. Crit Care Explor 2024; 6:e1120. [PMID: 38968159 PMCID: PMC11230760 DOI: 10.1097/cce.0000000000001120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2024] Open
Abstract
OBJECTIVES Interhospital transfer of patients with acute respiratory failure (ARF) is relevant in the current landscape of critical care delivery. However, current transfer practices for patients with ARF are highly variable, poorly formalized, and lack evidence. We aim to synthesize the existing evidence, identify knowledge gaps, and highlight persisting questions related to interhospital transfer of patients with ARF. DATA SOURCES Ovid Medline, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Embase, CINAHL Plus, and American Psychological Association. STUDY SELECTION We included studies that evaluated or described hospital transfers of adult (age > 18) patients with ARF between January 2020 and 2024 conducted in the United States. Using predetermined search terms and strategies, a total of 3369 articles were found across all databases. After deduplication, 1748 abstracts were screened by authors with 45 articles that advanced to full-text review. This yielded 16 studies that fit our inclusion criteria. DATA EXTRACTION The studies were reviewed in accordance to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews by three authors. DATA SYNTHESIS Included studies were mostly retrospective analyses of heterogeneous patients with various etiologies and severity of ARF. Overall, transferred patients were younger, had high severity of illness, and were more likely to have commercial insurance compared with nontransferred cohorts. There is a paucity of data examining why patients get transferred. Studies that retrospectively evaluated outcomes between transferred and nontransferred cohorts found no differences in mortality, although transferred patients have a longer length of stay. There is limited evidence to suggest that patients transferred early in their course have improved outcomes. CONCLUSIONS Our scoping review highlights the sparse evidence and the urgent need for further research into understanding the complexity behind ARF transfers. Future studies should focus on defining best practices to inform clinical decision-making and improve downstream outcomes.
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Affiliation(s)
- Amy Ludwig
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University, Chicago, IL
| | - Jennifer Slota
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Denise A. Nunes
- Galter Health Sciences Library, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kelly C. Vranas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Jacqueline M. Kruser
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, University of Wisconsin, Madison, WI
| | - Kelli S. Scott
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Reiping Huang
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Julie K. Johnson
- Northwestern Quality Improvement, Research, and Education in Surgery (NQUIRES), Department of Surgery, Northwestern University, Chicago, IL
| | - Tara C. Lagu
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern Feinberg School of Medicine, Chicago, IL
| | - Nandita R. Nadig
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University, Chicago, IL
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47
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Zhang D, Li L, Huang W, Hu C, Zhu W, Hu B, Li J. Vasoactive-Inotropic Score as a Promising Predictor of Acute Kidney Injury in Adult Patients Requiring Extracorporeal Membrane Oxygenation. ASAIO J 2024; 70:586-593. [PMID: 38324707 PMCID: PMC11210947 DOI: 10.1097/mat.0000000000002158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
Acute kidney injury (AKI) is a common complication in patients supported by extracorporeal membrane oxygenation (ECMO). Vasoactive-Inotropic Score (VIS) serves as an indicator of the extent of cardiovascular drug support provided. Our objective is to assess the relationship between the VIS and ECMO-associated AKI (EAKI). This single-center retrospective study extracted adult patients treated with ECMO between August 2016 and September 2022 from an intensive care unit (ICU) in a university hospital. A total of 126 patients requiring ECMO support were included in the study, of which 76% developed AKI. Multivariate logistic regression analysis identified VIS-max Day1 (odds ratio [OR]: 1.025, 95% confidence interval [CI]: 1.007-1.044, p = 0.006), VIS-max Day2 (OR: 1.038, 95% CI: 1.007-1.069, p = 0.015), VIS-mean Day1 (OR: 1.048, 95% CI: 1.013-1.084, p = 0.007), and VIS-mean Day2 (OR: 1.059, 95% CI: 1.014-1.107, p = 0.010) as independent risk factors for EAKI. VIS-max Day1 showing the best predictive effect (Area under the receiver operating characteristic curve (AUROC): 0.80, sensitivity: 71.87%, specificity: 80.00%) for EAKI with a cutoff value of 33.33. Surprisingly, VIS-mean Day2 was also excellent at predicting 7 day mortality (AUROC: 0.77, sensitivity: 87.50%, specificity: 56.38%) with a cutoff value of 8.67. In conclusion, VIS could independently predict EAKI and 7 day mortality in patients with ECMO implantation, which may help clinicians to recognize the poor prognosis in time for early intervention.
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Affiliation(s)
- Dandan Zhang
- From the Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, China
| | - Lu Li
- From the Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, China
| | - Weipeng Huang
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chang Hu
- From the Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, China
| | - Weiwei Zhu
- From the Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, China
| | - Bo Hu
- From the Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, China
| | - Jianguo Li
- From the Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, China
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48
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Sud S, Fan E, Adhikari NKJ, Friedrich JO, Ferguson ND, Combes A, Guerin C, Guyatt G. Comparison of venovenous extracorporeal membrane oxygenation, prone position and supine mechanical ventilation for severely hypoxemic acute respiratory distress syndrome: a network meta-analysis. Intensive Care Med 2024; 50:1021-1034. [PMID: 38842731 DOI: 10.1007/s00134-024-07492-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 05/13/2024] [Indexed: 06/07/2024]
Abstract
PURPOSE Severe acute respiratory distress syndrome (ARDS) with PaO2/FiO2 < 80 mmHg is a life-threatening condition. The optimal management strategy is unclear. The aim of this meta-analysis was to compare the effects of low tidal volumes (Vt), moderate Vt, prone ventilation, and venovenous extracorporeal membrane oxygenation (VV-ECMO) on mortality in severe ARDS. METHODS We performed a frequentist network meta-analysis of randomised controlled trials (RCTs) with participants who had severe ARDS and met eligibility criteria for VV-ECMO or had PaO2/FiO2 < 80 mmHg. We applied the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to discern the relative effect of interventions on mortality and the certainty of the evidence. RESULTS Ten RCTs including 812 participants with severe ARDS were eligible. VV-ECMO reduces mortality compared to low Vt (risk ratio [RR] 0.77, 95% confidence interval [CI] 0.59-0.99, moderate certainty) and compared to moderate Vt (RR 0.75, 95% CI 0.57-0.98, low certainty). Prone ventilation reduces mortality compared to moderate Vt (RR 0.78, 95% CI 0.66-0.93, high certainty) and compared to low Vt (RR 0.81, 95% CI 0.63-1.02, moderate certainty). We found no difference in the network comparison of VV-ECMO compared to prone ventilation (RR 0.95, 95% CI 0.72-1.26), but inferences were based solely on indirect comparisons with very low certainty due to very wide confidence intervals. CONCLUSIONS In adults with ARDS and severe hypoxia, both VV-ECMO (low to moderate certainty evidence) and prone ventilation (moderate to high certainty evidence) improve mortality relative to low and moderate Vt strategies. The impact of VV-ECMO versus prone ventilation remains uncertain.
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Affiliation(s)
- Sachin Sud
- Division of Critical Care, Department of Medicine, Trillium Health Center, University of Toronto, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada.
- Institute of Better Health, Trillium Health Partners, Mississauga, Canada.
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jan O Friedrich
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Hôpital Pitié-Salpêtrière, 75013, Paris, France
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 75013, Paris, France
| | - Claude Guerin
- Service de Médecine Intensive-Réanimation, Hôpital Edouard Herriot, Université de Lyon, Lyon, France
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
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Moynihan KM, Ryerson LM, Le J, Nicol K, Watt K, Gadepalli SK, Alexander PMA, Muszynski JA, Gehred A, Lyman E, Steiner ME. Antifibrinolytic and Adjunct Hemostatic Agents: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference. Pediatr Crit Care Med 2024; 25:e44-e52. [PMID: 38959359 PMCID: PMC11216380 DOI: 10.1097/pcc.0000000000003491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To derive systematic-review informed, modified Delphi consensus regarding antifibrinolytic and adjunct hemostatic agents in neonates and children supported with extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE consensus conference. DATA SOURCES A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION Use of antifibrinolytics (epsilon-aminocaproic acid [EACA] or tranexamic acid), recombinant factor VII activated (rFVIIa), or topical hemostatic agents (THAs). DATA EXTRACTION Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Eleven references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form. MEASUREMENTS AND MAIN RESULTS Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. One weak recommendation and three consensus statements are presented. CONCLUSIONS Evidence supporting recommendations for administration of antifibrinolytics (EACA or tranexamic acid), rFVIIa, and THAs were sparse and inconclusive. Much work remains to determine effective and safe usage strategies.
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Affiliation(s)
- Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Faculty of Medicine and Health, Children's Hospital at Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
- Department of Pediatric Cardiac Intensive Care, Stollery Children's Hospital, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta Hospital, Edmonton, AB, Canada
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, CA
- Department of Pathology, Nationwide Children's Hospital, Columbus, OH
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
- Division of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
- Ohio State University College of Medicine, Columbus, OH
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
- Divisions of Hematology/Oncology and Critical Care, Department of Pediatrics, University of Minnesota, Minnesota, MN
| | - Lindsay M Ryerson
- Department of Pediatric Cardiac Intensive Care, Stollery Children's Hospital, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta Hospital, Edmonton, AB, Canada
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, CA
| | - Kathleen Nicol
- Department of Pathology, Nationwide Children's Hospital, Columbus, OH
| | - Kevin Watt
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Samir K Gadepalli
- Division of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
- Ohio State University College of Medicine, Columbus, OH
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Marie E Steiner
- Divisions of Hematology/Oncology and Critical Care, Department of Pediatrics, University of Minnesota, Minnesota, MN
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50
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Tiruvoipati R, Akkanti B, Dinh K, Barrett NA, May A, Conrad SA. Extracorporeal Carbon Dioxide Removal With the Hemolung in Patients With Acute-on-Chronic Respiratory Failure: A Multicenter Retrospective Cohort Study. ASAIO J 2024; 70:594-601. [PMID: 38949772 DOI: 10.1097/mat.0000000000002155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Abstract
Extracorporeal carbon dioxide removal (ECCO2R) devices are increasingly used in treating acute-on-chronic respiratory failure caused by chronic lung diseases. There are no large studies that investigated safety, efficacy, and the independent association of prognostic variables to survival that could define the role of ECCO2R devices in such patients. This multicenter, multinational, retrospective study investigated the efficacy, safety of a single ECCO2R device (Hemolung) in patients with acute on chronic respiratory failure and identified variables independently associated with intensive care unit (ICU) survival. The primary outcome was improvement in blood gasses with the use of Hemolung. Secondary outcomes included reduction in tidal volume, respiratory rate, minute ventilation, survival to ICU discharge, and complication profile. Multivariable regression analysis was used to identify variables that are independently associated with ICU survival. A total of 62 patients were included. There was a significant improvement in pH and partial pressure of carbon dioxide in arterial blood (PaCO2) along with a reduction in respiratory rate, tidal volume, and minute ventilation with Hemolung therapy. The complication profile did not differ between survivors and nonsurvivors. Multivariable analysis identified the duration of Hemolung therapy to be independently associated with survival to ICU discharge (adjusted odds ratio = 1.21; 95% confidence interval [CI] = 1.040-1.518; p = 0.01).
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Affiliation(s)
- Ravindranath Tiruvoipati
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Medicine, Louisiana State University Health Sciences Centre, Shreveport, Louisiana
| | - Bindu Akkanti
- Division of Critical Care, Pulmonary and Sleep, Department of Medicine, University of Texas McGovern Medical School, Houston, Texas
| | - Kha Dinh
- Division of Critical Care, Pulmonary and Sleep, Department of Medicine, University of Texas McGovern Medical School, Houston, Texas
| | - Nicholas A Barrett
- Department of Critical Care, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human & Applied Physiological Sciences, Faculty of Life Sciences & Medicine, School of Basic & Medical Biosciences, King's College London, London, UK
| | - Alexandra May
- ALung Technologies, Inc., LivaNova, Pittsburgh, Pennsylvania
| | - Steven A Conrad
- Department of Medicine, Louisiana State University Health Sciences Centre, Shreveport, Louisiana
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